Acute mesenteric venous thrombosis: case for nonoperative management

Surgical and medical management of mesenteric ischemia

Acute mesenteric ischemia frequently results in bowel necrosis, which necessitates laparotomy to assess bowel viability. Reduction in mortality requires a high index of suspicion and prompt diagnosis. Bowel resection should be preceded by visceral artery revascularization. Medical management includes the use of anticoagulation, vasodilators, and the use of inhibitors of reperfusion injury. The management of chronic mesenteric ischemia largely depends on the general condition of the patient, who is often affected by malnutrition and dehydration. Surgery, although associated with greater morbidity and mortality, is more durable and effective in relieving the symptoms of chronic mesenteric ischemia. Endovascular treatment options for chronic mesenteric ischemia include percutaneous balloon angioplasty and stenting. This treatment is more likely to be successful in dealing with stenotic rather than occlusive lesions and offers a minimal invasive approach but is associated with a smaller primary success rate and a higher recurrence rate.

Deciphering mesenteric venous thrombosis: imaging and treatment

The principal cause of a high mortality rate in mesenteric vein thrombosis (MVT) is a delay in diagnosis. Recent data indicate that the mortality rate is decreasing owing to earlier diagnosis and anticoagulation. The authors examined the treatment profile of MVT to see how the increased use of imaging and early anticoagulation has impacted this process. They retrospectively analyzed the treatment paradigm with acute MVT at one institution over a 10-year period. Twenty-three patients were identified. Data were analyzed using chi-squares and Student's t tests. Twenty-three patients (11 men and 12 women with an average age of 51.74 +/-14.8 years) were identified with acute MVT between the years of 1993 and 2003. Five patients had splenic vein thrombosis, 17 had superior mesenteric vein thrombosis, 1 had inferior mesenteric vein thrombosis, and 12 had portal vein thrombosis. Nine patients had combination mesenteric vein segment thrombosis. Thrombolytics were utilized in a total of 6 patients. Four of the 6 patients in whom lytics were utilized had combined mesenteric vein thrombosis; however, these 4 patients did not require surgical intervention. There was no significant difference in length of hospital stay between patients taking lytics versus patients treated with traditional anticoagulation with heparin (p = 0.291). A hypercoagulable state was identified in 66.7% of the patients. Four patients required surgical intervention. The overall mortality rate was 8.7% (2 of 23). The use of thrombolytics was associated with a significant mortality (p = 0.04). The use of antibiotics made no difference in mortality (p = 0.235), nor did antibiotic use influence length of hospitalization (p = 0.192). MVT is relatively rare, and often the delay in diagnosis increases the mortality rate. In the majority of cases prompt anticoagulation will preserve bowel viability and decrease mortality and morbidity rates. The majority of patients do not need surgery. There is a marked increase in mortality rate when these patients progress to surgical intervention. An increased awareness and early diagnosis has led to decreased morbidity and mortality rates.

Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis

PURPOSE

The purpose of this study was to evaluate the utility of transcatheter thrombolytic therapy in 20 patients with acute or subacute (symptoms <40 days) portal and/or mesenteric vein thrombosis with severe symptoms, deteriorating clinical condition, and/or persistent symptoms despite anticoagulation.

MATERIALS AND METHODS

This retrospective study examined 12 male patients and eight female patients seen over a period of 11 years. The average age was 37.6 years. Four of the patients had previously undergone liver transplantation. An anatomic classification system was established to describe the extent of thrombus at the time of diagnosis. Patients were treated with thrombolytic therapy via the transhepatic route, common femoral vein route, and/or superior mesenteric artery route. Improvement in symptoms, avoidance of bowel resection, complications, and radiographic evidence of clot resolution were the main clinical outcomes.

RESULTS

Fifteen of the 20 patients exhibited some degree of lysis of the thrombus. Three patients had complete resolution, 12 had partial resolution, and five had no resolution. Eighty-five percent of patients (n = 17) had resolution of symptoms. Sixty percent of patients (n = 12) developed a major complication. No patients required bowel resection after thrombolytic therapy. One patient died with gastrointestinal hemorrhage and septic shock 2 weeks after thrombolytic therapy. Other major complications included bleeding and conditions requiring transfusion. No patients developed new portal or mesenteric thromboses. Two of the patients who received transplants eventually required repeat transplantation.

CONCLUSIONS

Transcatheter thrombolysis was beneficial in avoiding patient death, resolving thrombus, improving symptoms, and avoiding bowel resection. However, there was a high complication rate, indicating that this therapy should be reserved for patients with severe disease. Further evaluation of these techniques and outcomes should continue to be pursued.

Percutaneous Transhepatic Mechanical Thrombectomy for Acute Mesenteric Venous Thrombosis

PURPOSE

To present the management of symptomatic acute mesenteric venous thrombosis using a percutaneous thrombectomy device followed by resection of necrotic intestine.

CASE REPORT

A 60-year-old woman developed acute abdomen and melena. Diffuse and extensive mesenteric and portal vein thromboses were diagnosed by computed tomography. Percutaneous transhepatic mechanical thrombectomy with an Oasis thrombectomy device removed approximately 80% of the thrombus in the portal and superior mesenteric veins. The patient underwent laparotomy immediately after thrombectomy, in which 100 cm of necrotic intestine was resected. Catheter-directed urokinase thrombolysis was performed for 3 days to address residual thrombi. The result was excellent, and the patient recovered without short bowel syndrome.

CONCLUSIONS

The hydrodynamic thrombectomy system is a quick, reliable, efficient device that may offer an alternative to thrombolysis and surgical thrombectomy. Combining mechanical thrombectomy devices and surgery can be used to treat symptomatic acute mesenteric venous thrombosis.

Mesenteric and portal vein thrombosis: treated with early initiation of anticoagulation

OBJECTIVE

Superior mesenteric vein thrombosis (SMVT) is generally difficult to diagnose and can be fatal. Mesenteric and portal vein thrombosis is rare and can be presented as more serious conditions than that of SMVT. We report patients with combined SMVT and portal vein thrombosis (PVT) who were treated successfully with early initiation of anticoagulation.

METHODS

The medical records of six patients (five male, one female) who presented with combined SMVT and PVT in our institute between January 1994 and September 2003 were reviewed retrospectively. All of the patients were treated with early initiation of anticoagulation using unfractionated heparin or low molecular weight heparin.

RESULTS

The mean hospital stay was 31 days and the mean follow-up period was 32 months. Three patients had an antithrombin III deficiency. The most common symptom was diffuse abdominal pain and signs included abdominal distension and tenderness. During the follow-up period, there were two patients who developed stricture of the small bowel necessitating resection and anastomosis of the small bowel. There was no case of peritonitis due to bowel necrosis or mortality.

CONCLUSION

The early initiation of anticoagulation in patients of SMVT combined with PVT could minimise the serious complication such as peritonitis due to bowel necrosis required immediate exploratory laparotomy.

Mesenteric venous thrombosis with transmural intestinal infarction: a population-based study

OBJECTIVE

To determine the cause-specific mortality from and incidence of transmural intestinal infarction caused by mesenteric venous thrombosis (MVT) in a population-based study and to evaluate the findings at autopsy by evaluating autopsies and surgical procedures.

METHODS

All clinical (n = 23,446) and forensic (n = 7569) autopsies performed in the city of Malmö between 1970 and 1982 (population 264,000 to 230,000) were evaluated. The autopsy rate was 87%. The surgical procedures were performed in 1970, 1976, and 1982. Autopsy protocols coded for intestinal ischemia or mesenteric vessel occlusion, or both, were identified in a database. In all, 997 of 23,446 clinical and 9 of 7,569 forensic autopsy protocols were analyzed. A 3-year sample of the surgical procedures, comprising 21.3% (11,985 of 56,251) of all operations performed during the entire study period, was chosen to capture trends of diagnostic and surgical activity. In a nested case-control study within the clinical autopsy cohort, four MVT-free controls, matched for gender, age at death, and year of death were identified for each fatal MVT case to evaluate the clinical autopsy findings.

RESULTS

Four forensic and 23 clinical autopsies demonstrated MVT with intestinal infarction. Seven patients were operated on, of whom six survived. The cause-specific mortality ratio was 0.9:1000 autopsies. The incidence was 1.8/100,000 person years. At autopsy, portal vein thrombosis and systemic venous thromboembolism occurred in 2 of 3 and 1 of 2 of the cases, respectively. Obesity was an independent risk factor for fatal MVT (P =.021).

CONCLUSIONS

The estimated incidence of MVT with transmural intestinal infarction was 1.8/100,000 person years. Portal vein thrombosis, systemic venous thromboembolism and obesity were associated with fatal MVT.

Mesenteric Venous Thrombosis in a Patient with Pancreatitis and Protein C Deficiency

Mesenteric vein thrombosis is an uncommon manifestation of hypercoagulable states. A case is reported of superior mesenteric vein (SMV) thrombosis in a patient with pancreatitis and protein C deficiency. A discussion of SMV thrombosis identification, management, and outcomes is included. The patient presented with a significant history of alcohol abuse and constant, midepigastric abdominal pain associated with nausea and vomiting. Amylase and lipase were elevated, and the patient was treated for pancreatitis. His symptoms initially responded to intravenous fluid hydration, but soon his clinical picture worsened, with increased nausea and vomiting, abdominal pain, and distension. Contrasted computed tomography of the abdomen revealed SMV thrombosis. A hypercoagulable workup revealed protein C deficiency. After a 3-month course of oral anticoagulant therapy, the SMV thrombosis resolved.

Review article: diagnosis and management of mesenteric ischaemia with an emphasis on pharmacotherapy

Mesenteric ischaemia results from decreased blood flow to the bowel, causing cellular injury from lack of oxygen and nutrients. Acute mesenteric ischaemia (AMI) is an uncommon disorder with high morbidity and mortality, but outcomes are improved with prompt recognition and aggressive treatment. Five subgroups of AMI have been identified, with superior mesenteric artery embolism (SMAE) the most common. Older age and cardiovascular disease are common risk factors for AMI, excepting acute mesenteric venous thrombosis (AMVT), which affects younger patients with hypercoaguable states. AMI is characterized by sudden onset of abdominal pain; a benign abdominal exam may be observed prior to bowel infarction. Conventional angiography and more recently, computed tomography angiography, are the cornerstones of diagnosis. Correction of predisposing conditions, volume resuscitation and antibiotic treatment are standard treatments for AMI, and surgery is mandated in the setting of peritoneal signs. Intra-arterial vasodilators are used routinely in the treatment of non-occlusive mesenteric ischaemia (NOMI) and also are advocated in the treatment of occlusive AMI to decrease associated vasospasm. Thrombolytics have been used on a limited basis to treat occlusive AMI. A variety of agents have been studied in animal models to treat reperfusion injury, which sometimes can be more harmful than ischaemic injury. Chronic mesenteric ischaemia (CMI) usually is caused by severe obstructive atherosclerotic disease of two or more splanchnic vessels, presents with post-prandial pain and weight loss, and is treated by either surgical revascularization or percutaneous angioplasty and stenting.

[Spontaneous resolution of extensive superior mesenteric and portal vein thrombosis. A case report]

We present a case of subacute extensive thrombosis of the superior mesenteric vein, the venous branches of the jejunal vein, the portal vein at the hilum and its intrahepatic branches, with complete recanalization of the blood flow in the affected vessels without thrombolytic treatment. We provide a detailed description of the clinical and etiological investigations and outcome.

Mesenteric ischemia

MI remains a highly lethal entity. Improving survival requires an aggressive, multidisciplinary approach. High-risk patients with severe abdominal pain and a paucity of physical findings should be undergo emergent imaging in a search for this disease. Improvements in laboratory tests and advances in imaging techniques may improve the ability to diagnose MI earlier in its course, before irreversible damage has occurred. Many treatment modalities are available and should be tailored to each individual case. By recognizing and preventing ischemia-reperfusion injury,the cycle of protracted complications may be broken. A decrease in the mortality from MI finally is occurring. Early recognition and aggressive treatment finally may allow clinicians to have a marked impact on patient survival.

Source control in the management of severe sepsis and septic shock: An evidence-based review

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for source control in the management of severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and to improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591.

CONCLUSION

Source control represents a key component of success in therapy of sepsis. It includes drainage of infected fluids, debridement of infected soft tissues, removal of infected devices or foreign bodies, and finally, definite measures to correct anatomic derangement resulting in ongoing microbial contamination and to restore optimal function. Although highly logical, since source control is the best way to reduce quickly the bacterial inoculum, most recommendations are, however, graded as D or E due to the difficulty to perform appropriate randomized clinical trials in this respect. Appropriate source control should be part of the systematic checklist we have to keep in mind in setting up the therapeutic strategy in sepsis.