Mesenteric venous thrombosis: a diagnosis not to be missed!

Mesenteric venous thrombosis (MVT), an uncommon but important clinical entity, is one possible cause of ischemia or infarction of the small intestine. Diagnosis of this condition is sometimes difficult and treatment is often delayed because patients usually present with nonspecific abdominal symptoms. The hallmark is pain that is out of proportion to the physical findings. We report two cases of MVT, where the patients initially presented with vague abdominal symptoms. Diagnosis was made on the basis of computed tomography of the abdomen showing thrombus within the superior mesenteric vein. A search for a precipitating condition revealed no evidence of a hypercoagulable state, myeloproliferative disorder, or malignancy. These cases illustrate well the nonspecific clinical presentation of MVT. A high index of suspicion, recognition of known risk factors, or a previous history of venous thrombosis coupled with a history of nonspecific abdominal symptoms should alert clinicians to the possibility of MVT. Early diagnosis and prompt anticoagulation are the mainstay of therapy unless there are signs of peritonitis that necessitate surgical resection of the infarcted bowel.     

Superior mesenteric venous thrombosis during treatment of malignant lymphoma and of pure red cell aplasia

Mesenteric vein thrombosis is an uncommon type of intestinal ischemia that can be associated with significant mortality if its diagnosis is delayed. We experienced two patients with hematological disorders--non-Hodgkin's lymphoma (NHL) and pure red cell aplasia (PRCA)--who developed superior mesenteric vein (SMV) thrombosis during treatment. Neither of the patients had underlying disorders of the anticoagulant system that might have produced a hypercoagulable state. The first patient developed SMV thrombosis immediately after chemotherapy for NHL. This patient also had portal hypertension due to chronic hepatitis B. Direct injury to endothelial cells by the anti-cancer drugs and alteration of blood flow were the probable causes of the SMV thrombosis. The second patient with PRCA had regularly taken prednisolone, and this had induced a hypercoagulable state. The clinical symptoms of SMV thrombosis are usually non-specific, and in our patients vague, crampy abdominal pain without bloody diarrhea was the only complaint. Abdominal CT scan under a clinical suspicion of SMV thrombosis revealed the thrombi in the SMV. Urgent surgical resection of the infarcted bowel and immediate postoperative anticoagulation resulted in a favorable outcome. Clinicians should be aware of the vague symptoms of SMV thrombosis, as early diagnosis and urgent therapy are essential to prevent a fatal outcome.     

Superior Mesenteric Vein Thrombosis After Colectomy for Inflammatory Bowel Disease

PURPOSE: Thromboembolism is a significant cause of morbidity and mortality in inflammatory bowel disease. Several prothrombotic conditions have been investigated in inflammatory bowel disease. The aim of this study was to evaluate the incidence of symptomatic postoperative superior mesenteric vein thrombosis in inflammatory bowel disease patients undergoing colonic resections and to identify and characterize their clinical presentation. METHODS: Between January 1999 and December 2001, 83 consecutive patients undergoing total colectomy for inflammatory bowel disease were studied retrospectively. Patients who developed new-onset postoperative acute abdominal pain were evaluated by CT scan of the abdomen. A complete coagulation profile, including thrombin time, platelet count, protein C, protein S, antithrombin III, homocysteine level, factor V Leiden mutation, plasminogen, and prothrombin G20210A mutation, was obtained in patients diagnosed with superior mesenteric vein thrombosis. RESULTS: Four patients (4.8 percent; 3 females; 3 patients with ulcerative colitis and 1 with Crohn's colitis) developed symptomatic postoperative superior mesenteric vein thrombosis. Two of these patients had extension of the clot into the portal vein. Their presenting symptom was abdominal pain, with a median interval of ten days from the index surgery. The hematologic workup was negative in three patients, with one heterozygous for prothrombin G20210A mutation. All patients were treated with systemic anticoagulation for at least six months. One ulcerative colitis patient was diagnosed after abdominal colectomy and underwent an uneventful ileal pouch-anal anastomosis after systemic anticoagulation. CONCLUSION: Postoperative superior mesenteric vein thrombosis is a more frequent occurrence than previously reported in patients with inflammatory bowel disease. Direct surgical trauma to the middle colic veins, with resulting thrombosis, is likely to be the precipitating factor in a borderline intrinsically hypercoagulable environment. All patients became asymptomatic after systemic anticoagulation and recovered uneventfully.     

Mesenteric venous thrombosis. A retrospective study of 23 cases

Mesenteric venous thrombosis is uncommon. Diagnosis is difficult and much remains to be learned about clinical aspects, etiology and treatment options. PATIENTS AND METHODS: We conducted a retrospective study over 5 years concerning patients with isolated mesenteric venous thrombosis or with extension to the portal vein. RESULTS: Twenty-three patients (12 women), mean age 55 years, were included. Abdominal pain (96%), bowel obstruction (35%), fever (26%), diarrhea (17%), gastrointestinal bleeding (13%) were the most common symptoms at presentation. In 78% of patients, at least one underlying condition was identified: thrombophilia, oral contraceptive, cancer, paroxysmal nocturnal hemoglobinuria, essential thrombocythemia, intra-abdominal processes. CT scan and ultrasound diagnostic sensitivity were 89% and 57% respectively. Outcome was favorable for the 18 patients treated with anticoagulants (associated with surgery in 4 patients). Three patients with neoplasm died early. CONCLUSION: Mesenteric venous thrombosis must be kept in mind as a possible diagnosis in patients with abdominal pain. Predisposing factors are frequently associated and should be searched for. Early diagnosis, using CT scan or ultrasound, enables immediate anticoagulation and seems to improve outcome.     

A case of mesenteric venous thrombosis after endoscopic variceal band ligation

A rare case of isolated superior mesenteric venous thrombosis (MVT) after endoscopic variceal band ligation (EVL) is reported. A 64-year-old woman with a history of idiopathic portal hypertension presented at the emergency room with vomiting, increasing cramping abdominal pain, and low-grade fever. She had undergone EVL for esophageal varices 4 months before and had had intermittent attacks of mild abdominal pain after the EVL. Ultrasonogram of the abdomen demonstrated marked concentric wall thickening of the ileal loop. Enhanced computed tomographic (CT) scan revealed a central lucency in the lumen of the superior mesenteric vein, surrounded by a high-density vein wall, corresponding to a thrombus. An isolated MVT and venous collateral network in the splanchnic area were confirmed by angiography. Supportive therapy, i.e., water and electrolyte replacement, and anticoagulation improved the clinical condition and radiologic status. This case of MVT after EVL suggests a possible relationship between EVL and MVT. It is necessary for clinicians to be aware of this relationship for the early diagnosis of MVT.     

Acute superior mesenteric venous thrombosis: one disease or two?

OBJECTIVE: The aim of this study was to determine the etiology and natural history of acute superior mesenteric venous thrombosis (MVT) with and without splenic or portal vein involvement. METHODS: A retrospective analysis was carried out of patients with acute superior MVT evaluated between 1979 and 1998. Case records were reviewed and a questionnaire mailed to patients for follow-up evaluation. Also, a search was made to identify etiologies such as malignancy, infection, inflammatory bowel disease, and other risk factors. Patients were divided into two groups, isolated MVT or MVT with splenic or portal vein involvement. RESULTS: A specific etiology (malignancy, thrombophilia, inflammatory bowel disease, or surgery) was found in 35 of 69 patients. Thirty patients had isolated MVT with involvement predominantly of the small mesenteric veins; in the remaining 39 there was also portal or splenic vein involvement. Patients with isolated MVT were less likely to be diagnosed by imaging studies such as ultrasonography and CT and more likely to have bowel necrosis, and they required surgery more frequently. Inherited hypercoagulable disorders were more often found in patients with isolated MVT. During follow-up, six patients had recurrent MVT, and one patient with combined mesenteric and portal vein thrombosis developed variceal bleeding. CONCLUSIONS: Patients with isolated MVT are more likely to have hypercoagulable disorders. Isolated MVT is more difficult to diagnose and more likely to require surgery. Classification of patients with MVT into those with small vessel involvement or those with splenic or portal vein involvement thus has important clinical and prognostic value. Patients surviving the initial period have a good prognosis but definite risk of recurrence. Risk of variceal complications appears low.     

Portal and superior mesenteric venous thrombosis treated with urokinase infusion via superior mesenteric artery]

Portal and mesenteric venous thrombosis is an uncommon disease, but clinically important, because it accounts for 5% to 15% of acute mesenteric ischemia. The diagnosis is often delayed because the conditions are nonspecific abdominal symptoms. In addition, when this occurs in young individual without any known predisposing factor, the diagnosis may become even more difficult. The treatment of mesenteric venous thrombosis involves anticoagulation therapy alone or in combination with surgery. The addition of thrombolytic therapy to the treatment of portal and mesenteric venous thrombosis may enhance the clearance of thrombus and hasten the clinical improvements. We present a case of mesenteric venous thrombosis treated with catheter-directed infusion of urokinase via the superior mesenteric artery and systemic anticoagulation.     

肠系膜静脉血栓31例

目的:总结肠系膜静脉血栓形成(mesenteric venous thrombosis,MVT)的临床经验,探讨MVT形成的临床表现、诊断和治疗.方法:回顾性分析河北联合大学附属医院31例MVT住院患者的临床资料,调查其危险因素、既往血栓史、主诉和查体、实验室检查、放射学检查、治疗及预后.结果:1990-2010共收治MVT患者31例;男性24例,女性7例;平均年龄55.6岁;主要的临床表现为腹痛(100%)、呕吐(77.4%,24/31)、腹胀(64.5%,20/31)、便秘(41.9%,13/31);肝脏疾病、既往手术史、糖尿病和恶性肿瘤是MVT的主要高危因素;增强CT扫描是首选检查手段.7例患者接受单纯抗凝治疗,24例患者接受手术治疗;4例患者死亡.抗凝和手术治疗是MVT的主要治疗手段.结论:MVT临床表现无特异性;早期诊断,及时治疗是改善预后的关键.     

急性肠系膜静脉血栓形成30例临床分析

目的分析急性肠系膜静脉血栓形成的临床特点和治疗。方法对我院30例急性肠系膜静脉血栓患者的临床资料进行回顾性分析,并结合文献总结急性肠系膜静脉血栓的临床特点、诊断及治疗方法。结果30例急性肠系膜静脉血栓患者,年龄19～78岁,平均年龄51．9岁。手术治疗19例,死亡7例;溶栓治疗11例,放弃治疗1例。结论腹部CT可对早期急性肠系膜静脉血栓做出正确的诊断,早期溶栓或手术治疗可以降低死亡率。     

Value of CT and sonography in the conservative management of acute splenoportal and superior mesenteric venous thrombosis.

Acute splenoportal and superior mesenteric venous thrombosis were diagnosed on sonography and computed tomography (CT) in six patients. Sonography demonstrated the presence of echoic material filling the involved vessels in all patients. Precontrast CT scans demonstrated an increased, intra luminal density of the clots in four patients with splenoportal thrombosis. However, in two cases of superior mesenteric venous thrombosis, no hyperdensity was observed within the lumens. Nevertheless, the clots were always visualized as low-density regions in the vessel lumens after bolus injection. Intravenous anticoagulant therapy was started immediately after the diagnosis. All patients were evaluated twice a week with sonography and/or CT until recanalization occurred. The patency of the previously involved vessels was assessed from 6 days to 4 weeks after the acute episode (average time of recanalization: 17 days) without development of collateral pathways. It is concluded that, in the absence of clinical signs of a life-threatening process, a conservative management of acute splanchnic thrombosis can be successfully achieved by (1) early diagnosis, (2) efficacious intravenous anticoagulant therapy, (3) careful imaging follow-up of these patients by sonography and/or CT during the acute phase and, finally, (4) by an extensive search for a hypercoagulable state.     

Epiploic appendagitis: an uncommon and easily misdiagnosed disease

OBJECTIVE: Epiploic appendagitis (EA) is a rare cause of focal abdominal pain in otherwise healthy patients. It may mimic diverticulitis, appendicitis or mesenteric infarction on clinical manifestation. The diagnosis of EA is very infrequent due in part to low awareness by clinical physicians. The aim of this study was to review and describe the clinical presentation and computed tomography (CT) findings of EA. METHODS: Twenty‐one patients (6 women and 15 men, average age 40 years [range 27–65 years]) were diagnosed with EA by CT between January 2006 and October 2009. The patients' medical records were retrospectively reviewed with regard to their socioeconomic data, characteristics of abdominal pain, associated symptoms, laboratory results, radiological findings and treatment. RESULTS: Abdominal pain was the leading symptom. The pain was localized in the left lower quadrant (17 patients, 81.0%), left middle abdomen (2 patients, 9.5%) and right lower quadrant (2 patients, 9.5%), respectively. Leukocytosis (white blood cell > 10 × 10⁹/L) without left shift was found in 6 patients but all patients were afebrile. Characteristic CT findings of paracolonic oval hypodense fat tissue with thickened peritoneal ring and periappendageal fat stranding were all presented in 21 patients, but the central dot sign was presented in only 7 patients. They were all treated was conservative therapy. CONCLUSIONS: Epiploic appendagitis is the inflammatory response of an appendage to infarction or spontaneous venous thrombosis. A CT scan provides a definite diagnosis of epiploic appendagitis, thus avoiding unnecessary surgical intervention and antibiotics.     

Primary mesenteric venous thrombosis: a study from western India.

INTRODUCTION: The prevalence and clinical spectrum of mesenteric venous thrombosis (MVT) in India is largely unknown. METHODS: We retrospectively re-viewed the case records of patients with primary mesenteric venous thrombosis seen over a 10-year period and retrieved information on clinical picture, underlying hypercoagulable states and outcome. RESULTS: The 28 cases (mean age 41.2 [SD 10.2] years; 19 male) included 13 with acute MVT, 10 with subacute MVT and 5 with chronic MVT. Ten patients had past thromboembolic events (multiple events in five); four patients had isolated superior mesenteric vein involvement and 14 had multiple vessel involvement. Hypercoagulable state was identified in 17 patients, with multiple etiologies in 7 patients. Pre-operative diagnosis was made in all patients. Ten patients needed surgical management; the rest were managed medically initially, but 2 required surgery on follow up. Seven patients died during a follow up of up to 10 years, with in-hospital mortality during index admission in six. CONCLUSIONS: Most of the patients with MVT have multiple intra-abdominal vessel involvement and underlying hypercoagulable state. The policy of early treatment with anticoagulation in all and surgical treatment as per need, achieves low mortality.     

经TIPSS途径门静脉及肠系膜上静脉血栓溶栓治疗

目的 评价经TIPSS途径门静脉及肠系膜上静脉血栓溶栓治疗的安全性和效果。方法 对6例诊断为PV和SMV广泛血栓形成患者进行了经颈静脉途径经肝穿刺门静脉(简称TIPSS途径)介入溶栓治疗。患者主要症状有腹痛、腹胀、厌食等。腹部体检有压痛，均无明确腹肌紧张和反跳痛。B超、增强CT检查和直接PV-SMV造影确诊为本病。溶栓方法：穿刺PV分支成功后插入导管做PV-SMV造影，确定诊断及了解栓塞范围，抽吸及捣碎血栓，间断将尿激酶经多侧孔导管注入PV和SMV清除大部分血栓后，保留多侧孔导管至SMV内持续溶栓3天-13天。术后药物抗凝治疗6个月左右，此间，密切监测出凝血时间及影象学血变化。结果 介入治疗后，大部分血栓被清除，PV和SMV有血流通过，腹痛、腹胀和腹泻症状逐步缓解。经留置于SMV的导管造影显示PV和SMV主干及主要分支血流通畅，3例门静脉肝内少数分支有残留血栓，但无明显症状。随访4个月至3年，除1例死于外科手术并发症外，其余5例健在、无血栓复发证据及上消化道出血发生。结论 经TIPSS途径介入技术溶栓治疗，是治疗急性PV和SMV血栓形成的安全、具有良好的近期及中远期疗效的方法。     

Screening for hypercoagulable syndromes following stroke

Patients with ischemic stroke of unclear etiology are often screened for hypercoagulable syndromes or thrombophilias. These have been recognized to cause venous thrombosis, and include hereditary deficiencies of coagulation factors, genetic mutations, or acquired disorders. However, the majority of coagulation disorders are only rarely associated with ischemic stroke. The tests most commonly used to screen for thrombophilias comprise a complex array of assays that may be unreliable in various settings, including acute thrombosis, inflammation, and uses of medications such as anticoagulants. The diagnostic yield of thrombophilia tests in unselected stroke patients is very low, but may improve with careful selection of younger patients who have an otherwise undetermined cause of stroke or a history of venous thrombosis or multiple miscarriages. Various strategies have been developed that can guide the selection of patients (based on specific characteristics) and tests in the evaluation of thrombophilias. Although the diagnosis of thrombophilia aids in the potential explanation of stroke etiology, the best regimen for secondary prevention treatment for the majority of thrombophilias is still unknown.     

急性肠系膜静脉血栓形成8例临床分析

目的探讨急性肠系膜静脉血栓形成(AMVT)的诊治要点。方法回顾性分析我院1995年7月至2003年6月经手术确诊的8例AMVT的临床特点及诊治情况。结果8例术前均以急腹症就诊,疑诊AMVT2例,8例均手术后确诊。1例为肠系膜上静脉主干血栓形成,全小肠坏死,术后2d死亡。余7例部分肠系膜静脉栓塞及肠坏死,6例治愈,1例并发双下肢深静脉血栓形成。5例明确病因。结论AMVT大多数以急腹症就诊,早期腹痛明显而体征轻微是其临床特点,临床诊断较困难。对有急性弥漫性腹膜炎、可疑肠坏死和血流动力学不稳的患者应立即手术治疗。     

Budd-Chiari syndrome in a patient with ulcerative colitis and no inherited coagulopathy

We report a case of 27 year old female patient who was admitted to the hospital with an acute flare up of ulcerative colitis.The patient presented with complaints of persistent abdominal pain and bloody diarrhea despite aggressive therapy for her ulcerative colitis.A CT scan of the abdomen on admission revealed hepatic vein thrombosis,suggesting a diagnosis of Budd-Chiari syndrome.Significantly,an associated thrombosis of the inferior mesenteric vein was also detected.Based on imaging data and clinical assessment,the patient was started on anticoagulation therapy and an extensive work-up for hypercoagulability was initiated.Up to the time of publication,no significant findings suggesting this patient has an underlying coagulation disorder have been found.Based on our search of PUBMED,this report is one of only five reported adult cases of Budd-Chiari Syndrome associated with ulcerative colitis in the English literature in living patients without evidence of a co-existing coagulation disorder.This case highlights the potential for thrombosis at unusual sites in ulcerative colitis patients even in the absence of classical coagulation abnormalities.In addition to the case presented,we provide a brief review of previously reported cases of Budd-Chiari Syndrome occurring in patients with inflammatory bowel disease.     

Jujitsu kick to the abdomen: a case of blunt abdominal trauma resulting in hematochezia and transient ischemic colitis

Blunt abdominal trauma is a common presentation to the emergency department. Ischemic colitis is a rare complication of this and its possible sequelae are important for an emergency physician to recognize. A 21-year-old man presented to the emergency department with abdominal pain and hourly episodes of bright red blood per rectum shortly after being kicked in the stomach at his jujitsu class. He had no significant medical history, and results of his systems review were otherwise unremarkable. On examination, he appeared well, with normal vital signs. He had mild lower abdominal tenderness, but there were no peritoneal signs present. There was blood on the digital rectal examination. His hemoglobin, platelet, and international normalized ratio levels were normal and his abdominal radiograph was unremarkable. The gastroenterology service was contacted because of the hematochezia and a flexible sigmoidoscopy was performed. The sigmoidoscopy showed erythema, ulceration, and edema of a segment in the left colon, consistent with ischemic colitis. This was later confirmed on biopsy. A computed tomography (CT) scan of the abdomen was conducted, which revealed left colonic inflammation consistent with colonic ischemia. There was no mesenteric vascular thrombosis or mesenteric hematoma found on CT. His hematochezia and abdominal pain subsided spontaneously, and he was discharged home. This case illustrates transient ischemic colitis as a potential presentation of blunt abdominal trauma, and emergency physicians should consider this uncommon diagnosis in the differential diagnosis of patients presenting after abdominal trauma.     

Isolated superior mesenteric artery thrombosis: a rare cause for recurrent abdominal pain in a child

A 4-year-old boy was evaluated for recurrent abdominal pain and failure to thrive over a 1-year period in a pediatric subspecialty clinic. Results of the extensive workup mostly were unremarkable. Eventually, imaging studies of the abdominal aorta revealed an isolated thrombosis of the superior mesenteric artery trunk and compensatory hypertrophy of the inferior mesenteric artery. He had been having abdominal angina symptoms and fear of eating. A detailed family history suggested a possible hypercoagulable state. However, an extensive hematologic evaluation did not reveal a recognizable defect that could produce thrombotic events. He was treated by arterial graft bypass surgery and started on conventional anticoagulants. Several months later, he developed repeat, near-total thrombosis of the graft with recurrence of his symptoms. After balloon dilation of the graft and starting him on appropriate anticoagulant maintenance regimen, he had good symptom relief, and the graft remained patent. This presentation was unusually prolonged for the type of vascular problem identified. The possibility of vascular problems in children, therefore, should be considered. Unidentified cause of hereditary clotting tendency is another challenging aspect of this case.     

A case of portal vein thrombosis caused by blunt abdominal trauma in a patient with low protein C activity

Portal vein thrombosis (PVT) is caused by several conditions including infection, malignancies, surgery, medications, and coagulation disorders. However, PVT caused by low-energy injury is very rare. A 51-year-old man visited a clinic with a 2-day history of abdominal pain following blunt abdominal trauma. Contrast-enhanced computed tomography (CT) revealed thrombosis in both the portal vein and splenic vein, and he was transferred to our hospital with a diagnosis of PVT. Anticoagulant therapy was initiated using unfractionated heparin. A repeat CT scan revealed enlargement of the thrombus, which occluded the main trunk and first right branch of the portal vein. Laboratory data before heparin administration suggested low protein C activity. Anticoagulation therapy was continued with intermittent assessment of the size of the thrombus and degree of coagulation. On day 23, enhanced CT showed marked shrinkage of the thrombus compared with that on day 8. On day 30, the patient was discharged with a therapeutic prothrombin time–international normalized ratio. Here we present a case of PVT caused by low-energy trauma of the upper abdomen in a patient with a background of low protein C activity that was successfully treated without invasive surgery.     

Deep venous thrombosis and the risk of pulmonary embolism. A systematic study.

The influence of several diseases and clinical conditions on the presence of pulmonary embolism (PE) in a large series of patients with deep venous thrombosis (DVT) in the lower extremities was analyzed prospectively. Lung scan findings from a series of 434 consecutive patients with DVT (with and without symptoms of PE) were studied and then correlated to five clinical variables: age, sex, elapsed time since clinical symptoms had appeared in the leg to diagnosis, degree of proximity of venous thrombus, and the presence or not of several risk factors that could have predisposed to thrombus development. According to scintigraphic findings, 164 patients were considered to have PE (asymptomatic in 76 of them), while 200 patients were classified as having only DVT. Lung scan was considered to be indeterminate for PE in 70 patients, and they were not included in the study. No differences were found in terms of age, sex, interval of time elapsed since onset of symptoms to diagnosis, or in the degree of proximity of the thrombus. However, several differences between groups were found when comparing the presence or absence of several predisposing factors for thrombosis: DVT developing in immobilized patients was associated with a significantly lower incidence of PE as compared with nonimmobilized patients (p = 0.005). Conversely, patients with a history of venous thromboembolism (VTE) had a significantly higher rate of embolism (31/51 vs 133/313; p = 0.01). On logistic regression analysis, a history of VTE showed a statistically significant association with more than a twofold higher risk of having PE for patients with such an antecedent. Our findings suggest that different pathophysiologic pathways could perhaps explain differences in embolic potential.