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Thomas AD, Rocker MD, Morris-Stiff G, Lewis MH. Gastro-colonic anastomosis--a viable option in extensive small bowel infarction. Ann R Coll Surg Engl 2006; 88:26. [PMID: 16468135 PMCID: PMC1963636 DOI: 10.1308/147870806x83251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We have previously presented a patient with massive small and large bowel infarction and demonstrated that even with only a few inches of remaining small bowel an almost normal life-style and diet is possible. PATIENT Recently, we have looked after a young and otherwise fit female patient who suffered mesenteric venous gangrene of the whole small bowel from the Ligament of Treitz to the caecum. In order to achieve gastro-intestinal continuity and to avoid the torrential fluid loss associated with high fistula, an anastomosis between the stomach and the transverse colon was formed. RESULTS We are surprised to find that despite the extensive resection our patient maintains a good quality of life and is able to look after her young family.
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Affiliation(s)
- A D Thomas
- Department of Surgery, Royal Glamorgan Hospital, Llantrisant, UK
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302
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Puurunen M, Lassila R. Successful treatment of mesenterial venous thrombosis with recombinant hirudin—a report of five cases. Thromb Res 2006; 118:241-5. [PMID: 16009402 DOI: 10.1016/j.thromres.2005.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Revised: 05/10/2005] [Accepted: 06/05/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Marja Puurunen
- Helsinki University Central Hospital, Department of Medicine, Division of Hematology, Coagulation Disorders, Finland
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303
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Karamlou T, Landry GJ, Taylor LM, Moneta GL. Epidemiology and Pathophysiology. Vasc Med 2006. [DOI: 10.1016/b978-0-7216-0284-4.50031-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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304
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Johnson CM, de la Torre RA, Scott JS, Johansen T. Mesenteric venous thrombosis after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2005; 1:580-2; discussion 582-3. [PMID: 16925296 DOI: 10.1016/j.soard.2005.08.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2005] [Revised: 07/27/2005] [Accepted: 08/01/2005] [Indexed: 01/04/2023]
Affiliation(s)
- Colleen M Johnson
- Division of Vascular Surgery, University of Missouri-Columbia, Columbia, Missouri
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305
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Hollingshead M, Burke CT, Mauro MA, Weeks SM, Dixon RG, Jaques PF. Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis. J Vasc Interv Radiol 2005; 16:651-61. [PMID: 15872320 DOI: 10.1097/01.rvi.0000156265.79960.86] [Citation(s) in RCA: 187] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Michael Hollingshead
- Department of Radiology, University of North Carolina Chapel Hill, 27599-7510, USA
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306
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Houénassi DM, Olory-Togbé JL, Tchabi Y, Sacca-Véhounkpé J, Akindès RDY, Massougbodji MD, Agboton H. [Atypical venous thrombosis and protein S deficiency: report of a case]. Ann Cardiol Angeiol (Paris) 2005; 54:220-2. [PMID: 16104624 DOI: 10.1016/j.ancard.2004.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
A 29 year old man is admitted for hypovemic shock and abdominal pain. This critical condition was due to a diffuse mesenteric venous thrombosis and intestinal infarction. Five meters of small bowel are resected. Few days later a superficial brachial venous thromboembolism grows to superior cava venous and bilateral pulmonary embolism. A plasmatic protein S level was 17%. This deficiency is considered to be the support of these atypical extended and repetitive venous thromboembolism. With an optimal nutrition and long oral anticoagulation this patient is alive 17 months after his admission.
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Affiliation(s)
- D M Houénassi
- Unité de soins d'enseignement et de recherche en cardiologie, faculté des sciences de la santé, université d'Abomey-Calavi, 01 BP 188 Cotonou, Bénin.
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307
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Takahashi N, Kuroki K, Yanaga K. Percutaneous Transhepatic Mechanical Thrombectomy for Acute Mesenteric Venous Thrombosis. J Endovasc Ther 2005; 12:508-11. [PMID: 16048384 DOI: 10.1583/04-1335mr.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Naoto Takahashi
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
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308
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Abstract
Chronic mesenteric ischemia is an unusual but important cause of abdominal pain. Although this condition accounts for only 5% of all intestinal ischemic events, it can have significant clinical consequences. Among its many causes, atherosclerotic occlusion or severe stenosis is the most common. This disorder has an indolent course that results in extensive collateral vascular formation. Thus, symptoms occur when at least two of the three main splanchnic vessels are affected. Intestinal angina, weight loss, and sitophobia are common clinical features. Diagnosis can often be made by noninvasive methods such as computerised axial tomographic angiography, magnetic resonance angiography, and duplex ultrasonography as well as by invasive catheter angiography. Therapy of chronic mesenteric ischemia depends on the extent and location of vascular disease. Alternatives to traditional surgical bypass are becoming more common including embolectomy, thrombolysis, and percutaneous angioplasty with vascular stenting. Early intervention is vital as the natural course of this illness can be debilitating. Furthermore, this has potential to develop into life-threatening acute mesenteric ischemia with subsequent bowel infarction and death. Long-term studies have shown that the risk of developing symptoms from asymptomatic but significant mesenteric vascular disease is 86% with overall 40% mortality rate. The recognition and management of this unusual but important cause of abdominal pain is discussed in detail in this review.
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Affiliation(s)
- Jayaprakash Sreenarasimhaiah
- Department of Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern, 5323 Harry Hines Blvd, MC 8887, Dallas, TX 75390-9083, USA.
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309
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Rackoff A, Shores N, Willner I. Mesenteric Venous Thrombosis in a Patient with Pancreatitis and Protein C Deficiency. South Med J 2005; 98:232-4. [PMID: 15759957 DOI: 10.1097/01.smj.0000145305.95081.92] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Andrew Rackoff
- Department of Medicine and Digestive Disease Center, Medical University of South Carolina, Charleston, SC 29425, USA.
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310
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Espeel B, Gérard C, Mansvelt B, Bertrand C, Vermonden J. [Extensive mesenteric venous thrombosis treatment by regional thrombolysis]. ACTA ACUST UNITED AC 2005; 24:274-7. [PMID: 15792561 DOI: 10.1016/j.annfar.2004.12.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2004] [Accepted: 12/13/2004] [Indexed: 12/11/2022]
Abstract
Two cases of mesenteric venous thrombosis with portal extension are reported. The first patient was treated right away by local intra-arterial thrombolysis, the second one benefited from local venous thrombolysis immediately after intestinal resection. No significant complication was observed.
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Affiliation(s)
- B Espeel
- Service de réanimation polyvalente, centre hospitalier Jolimont-Lobbes, hôpital de Jolimont, 159, rue Ferrer, 7100 Haine-Saint-Paul, Belgique.
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311
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Fernández-Marcote Menor EM, Opio Maestro VA. [Spontaneous resolution of extensive superior mesenteric and portal vein thrombosis. A case report]. GASTROENTEROLOGIA Y HEPATOLOGIA 2005; 27:470-2. [PMID: 15388052 DOI: 10.1016/s0210-5705(03)70506-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
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.
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312
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Webster GJM, Burroughs AK, Riordan SM. Review article: portal vein thrombosis -- new insights into aetiology and management. Aliment Pharmacol Ther 2005; 21:1-9. [PMID: 15644039 DOI: 10.1111/j.1365-2036.2004.02301.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Portal vein thrombosis may occur in the presence or absence of underlying liver disease, and a combination of local and systemic factors are increasingly recognized to be important in its development. Acute and chronic portal vein thrombosis have traditionally been considered separately, although a clear clinical distinction may be difficult. Gastrooesophageal varices are an important complication of portal vein thrombosis, but they follow a different natural history to those with portal hypertension related to cirrhosis. Consensus on optimal treatment continues to be hampered by a lack of randomized trials, but recent studies demonstrate the efficacy of thrombolytic therapy in acute thrombosis, and the apparent safety and benefit of anticoagulation in patients with chronic portal vein thrombosis.
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Affiliation(s)
- G J M Webster
- Department of Gastroenterology, University College London Hospitals NHS Trust, London, UK.
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313
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Ramos-Gallo M, Vaquero-Lorenzo F, Vallina-Vázquez M, Álvarez-Fernández L. Trombosis venosa mesentérica aguda como causa de isquemia. ANGIOLOGIA 2005. [DOI: 10.1016/s0003-3170(05)74925-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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314
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Bailey KA, Bass J, Nizalik E, Jimenez C. Unusual case of mesenteric venous thrombosis associated with oral contraceptive use in an adolescent girl. Pediatr Dev Pathol 2005; 8:128-31. [PMID: 15719204 DOI: 10.1007/s10024-004-7079-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2004] [Accepted: 10/06/2004] [Indexed: 10/25/2022]
Abstract
A 16-year-old girl presented with hematochezia and abdominal pain. The patient developed a small bowel obstruction that required a laparotomy, which showed a segment of grossly infarcted small bowel with 3 perforations, localized abscesses, and creeping fat. Resection and an end-to-end anastomosis were performed. Pathologic examination showed underlying mesenteric venous thrombosis with no evidence of Crohn's disease. Hematology workup showed no evidence of a congenitally inherent hypercoagulable state. The use of oral contraceptives was the only predisposing factor identified.
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Affiliation(s)
- Karen A Bailey
- Department of Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
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315
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Zhang J, Duan ZQ, Song QB, Luo YW, Xin SJ, Zhang Q. Acute mesenteric venous thrombosis: a better outcome achieved through improved imaging techniques and a changed policy of clinical management. Eur J Vasc Endovasc Surg 2004; 28:329-34. [PMID: 15288639 DOI: 10.1016/j.ejvs.2004.06.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2004] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To analyse and compare the results obtained from acute mesenteric venous thrombosis (MVT) patients before and after the change of the clinical management principle, to assess the factors responsible for the recent better outcome and determine the best management for this disease. MATERIALS AND METHODS We retrospectively reviewed 41 patients treated for acute MVT admitted in our hospital between 1978 and 2003. Before 1995 (Group I), our policy was to perform surgery in patients with suspected acute MVT. After 1995 (Group II), we changed our policy to a medical approach when achievable. Each patient in this study was assessed for diagnosis, initial management (operative or non-operative), mortality, duration of hospitalisation, and outcome. RESULTS There were 13 in Group I, 28 in Group II. The mean duration of diagnoses made after admission was 7.3 S.D. 2.6 days for patients in Group I, and 1.5 S.D. 1.2 days for those in Group II (p<0.01, Student's t-test). Eleven patients underwent operations and two patients received non-operative treatment initially in group I, the mortality was 39%; while nine patients underwent operations and 19 patients received non-operative management in group II, the mortality was 11% (p<0.05). No death occurred in the patients with initial non-operative management. The mean duration of hospitalisation was 26 S.D. 6.8 days in Group I and 12.6 S.D. 4.6 days in Group II (p<0.01, Student's t-test). No significant difference in 2-year survival rate between the two groups. CONCLUSION Recent improvements in imaging techniques and better understanding of the aetiology have led to a dramatic change in the principle and policy of clinical management for acute MVT, which leads to a more favourable outcome of acute MVT.
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Affiliation(s)
- J Zhang
- Third General Surgery Department, First Affiliated Hospital, China Medical University, Shenyang 110001, China.
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316
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Abstract
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.
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Affiliation(s)
- Joseph P Martinez
- Department of Surgery, Division of Emergency Medicine, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
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317
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Choi SH, Lee JM, Lee KH, Kim SH, Kim YJ, An SK, Han JK, Choi BI. Relationship Between Various Patterns of Transient Increased Hepatic Attenuation on CT and Portal Vein Thrombosis Related to Acute Cholecystitis. AJR Am J Roentgenol 2004; 183:437-42. [PMID: 15269038 DOI: 10.2214/ajr.183.2.1830437] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We sought to investigate the prevalence of portal vein thrombosis in patients with acute cholecystitis and the relationship between portal vein thrombosis and the various patterns of transient increased hepatic attenuation on CT. MATERIALS AND METHODS We studied 72 of 107 patients with acute cholecystitis who, during a 3-year period, underwent dual-phase contrast-enhanced CT before percutaneous cholecystostomy or cholecystectomy. CT scans were retrospectively reviewed for the presence of portal vein thrombosis and location of the thrombi and for patterns of transient increased hepatic attenuation, which were classified as either pericholecystic, segmental, or mixed. RESULTS Portal vein thrombi (two in hepatic segment IV, three in the left portal vein, and one in the right posterior portal vein) were found in six (8.3%) of 72 patients, and in those patients, transient increased attenuation with a segmental (five patients) or mixed (one patient) pattern was seen on CT. The pattern of transient increased attenuation in the 54 patients without portal vein thrombosis was pericholecystic in 41 (75.9%) and mixed in 13 (24.1%). Nineteen patients had segmental distribution (segmental or mixed pattern) that in 31.6% (6/19) of the patients was associated with portal vein thrombosis. Segmental distribution was more frequently found in those patients who had acute cholecystitis with portal vein thrombosis than in those who had only acute cholecystitis (p = 0.001). CONCLUSION In patients with acute cholecystitis, portal vein thrombosis is not uncommon. Patterns of transient increased hepatic attenuation were found to vary, depending on the presence or absence of portal vein thrombosis.
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Affiliation(s)
- Seung Hong Choi
- Department of Radiology and Institute of Radiation Medicine, Seoul National University Hospital, 28, Yongon-dong, Chongno-gu, Seoul 110-744, South Korea
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318
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319
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Affiliation(s)
- R Antonescu
- Fondation Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75674 Paris Cedex 14
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320
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Corne P, Borie F, Gallix B, Landreau L, Millat B, Jonquet O. [Splenic infarct revealing meningococcemia]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28:197-8. [PMID: 15060471 DOI: 10.1016/s0399-8320(04)94881-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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321
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Abstract
Ischemic bowel disease includes acute and chronic mesenteric ischemia, and colon ischemia. Cross-sectional imaging, and more particularly computed tomography, has an increasing role in the detection of acute and chronic mesenteric ischemia. Vascular obstructions or stenoses and changes in the bowel wall can be observed. Functional information can be added with MRI by using sequences that are sensitive to oxygen saturation in the superior mesenteric vein. Arteriography remains the reference examination in patients with acute mesenteric ischemia.
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Affiliation(s)
- B E Van Beers
- Département d'imagerie médicale, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, B-1200 Bruxelles, Belgique.
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322
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Sturm W, Gaenzer H, Heininger-Rothbucher D, Neumayr G, Kirchmair R, Patsch J, Weiss G. Unsuspected mesenteric vein thrombosis in a patient with a hereditary bleeding disorder. Blood Coagul Fibrinolysis 2003; 14:599-600. [PMID: 12960615 DOI: 10.1097/00001721-200309000-00013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report on a female patient with hereditary hemorrhagic teleangiectasia complicated by subacute thrombosis of the superior mesenteric vein. Despite gastrointestinal bleeding, anticoagulation therapy with heparin had to be performed to prevent bowel infarction. In this case, local vascular lesions with altered blood flow in combination with hyperfibrinogenemia might have caused superior mesenteric vein thrombosis.
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Affiliation(s)
- Wolfgang Sturm
- Department of Internal Medicine, University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
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323
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Hambleton J, Leung LL, Levi M. Coagulation: consultative hemostasis. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2003:335-52. [PMID: 12446431 DOI: 10.1182/asheducation-2002.1.335] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Clinical hematologists are frequently consulted for the care of hospitalized patients with complicated coagulopathies. This chapter provides an update on the scientific and clinical advances noted in disseminated intravascular coagulation (DIC) and discusses the challenges in hemostasis consultation. In Section I, Dr. Marcel Levi reviews advances in our understanding of the pathogenic mechanisms of DIC. Novel therapeutic strategies that have been developed and evaluated in patients with DIC are discussed, as are the clinical trials performed in patients with sepsis. In Section II, Dr. Lawrence Leung provides an overview of the challenging problems in thrombosis encountered in the inpatient setting. Patients with deep vein thrombosis that is refractory to conventional anticoagulation and those with extensive mesenteric thrombosis as well as the evaluation of a positive PF4/heparin ELISA in a post-operative setting are discussed. Novel treatments for recurrent catheter thrombosis in dialysis patients is addressed as well. In Section III, Dr. Julie Hambleton reviews the hemostatic complications of solid organ transplantation. Coagulopathy associated with liver transplantation, contribution of underlying thrombophilia to graft thrombosis, drug-induced microangiopathy, and the indication for postoperative prophylaxis are emphasized. Dr. Hambleton reviews the clinical trials evaluating hemostatic agents in patients undergoing liver transplantation.
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Affiliation(s)
- Julie Hambleton
- Hemostasis and Thrombosis, Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, 94143, USA
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324
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Johnson CA, Parker MV, Goff JM. Mesenteric venous thrombosis in a patient with prothrombin 20210A mutation and antithrombin III deficiency: challenges to conventional anticoagulation--a case report. Vasc Endovascular Surg 2003; 37:293-6. [PMID: 12894373 DOI: 10.1177/153857440303700410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mesenteric venous thrombosis presents as vague abdominal pain in patients with a medical or family history suggestive of a hypercoagulable state. Classic computed tomography findings will often confirm the diagnosis, and the presence of persistent abdominal pain or tenderness will determine the need for surgical intervention. Expeditious anticoagulation is the treatment of choice. This case demonstrates the CT findings for mesenteric venous thrombosis and discusses the challenges of anticoagulation in a patient with 2 hypercoagulable disorders.
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Affiliation(s)
- Chatt A Johnson
- Vascular Surgery Department, Walter Reed Army Medical Center, Washington, DC, USA
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325
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Abstract
Although intestinal ischaemia is an infrequent event, early recognition and appropriate treatment can reduce the potential for a devastating outcome
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Affiliation(s)
- Jayaprakash Sreenarasimhaiah
- Department of Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, MC 8887, Dallas, TX 75390, USA.
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326
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Abstract
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.
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Affiliation(s)
- Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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327
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Baker ME, Remzi F, Einstein D, Oncel M, Herts B, Remer E, Fazio V. CT depiction of portal vein thrombi after creation of ileal pouch-anal anastomosis. Radiology 2003; 227:73-9. [PMID: 12616004 DOI: 10.1148/radiol.2271020032] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine the presence and location of portal vein thrombi in patients who have undergone ileal pouch-anal anastomosis (IPAA) and who were scanned with computed tomography (CT). MATERIALS AND METHODS During a 4-year period, 92 of 702 patients underwent contrast medium-enhanced CT after a total proctocolectomy with an IPAA. These CT scans were retrospectively reviewed for portal vein thrombus presence, location, and occlusive nature, as well as any accompanying enhancement abnormalities of the hepatic parenchyma. Only 13 patients who had initial CT scans that were positive for thrombi underwent follow-up examinations, and these were reviewed for resolution or progression of the original findings. RESULTS Portal vein thrombi were present in 41 (45%) of the 92 patients; 24 (59%) of the 41 were isolated, often multiple, segmental right lobe thrombi. Five patients had both right and left segmental vein involvement. Eleven patients had various combinations of main portal vein, right and left portal vein, or segmental vein thrombi. One patient had an isolated superior mesenteric vein thrombus. Twenty-two of 25 superior mesenteric vein, main portal vein, and right and left portal vein thrombi were nonocclusive, while most (63 of 86) of the segmental vein thrombi were occlusive. Wedge-shaped, peripheral areas of hepatic parenchymal hyperenhancement that were distal to the thrombi were present in 30 (73%) of the 41 patients. Follow-up scans obtained in the 13 patients with portal vein thrombi showed thrombi resolved in five patients, progression to cavernous transformation occurred in one patient, and parenchymal enhancement changes persisted in seven patients. In the seven patients with persistent enhancement changes, four had complete resolution of thrombi. CONCLUSION Portal vein thrombi appear to be relatively common after IPAA surgery and are most likely segmental, multiple, and occlusive. Peripheral wedge-shaped areas of hepatic parenchymal hyperenhancement commonly accompany these thrombi.
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Affiliation(s)
- Mark E Baker
- Department of Radiology, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA.
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Macari M, Chandarana H, Balthazar E, Babb J. Intestinal ischemia versus intramural hemorrhage: CT evaluation. AJR Am J Roentgenol 2003; 180:177-84. [PMID: 12490499 DOI: 10.2214/ajr.180.1.1800177] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE We evaluated the capability of CT to depict findings that allowed differentiation of small-bowel ischemia from intramural hemorrhage. MATERIALS AND METHODS Findings of 35 CT examinations (19 patients with small-bowel ischemia and 16 patients with intramural hemorrhage) were analyzed by two abdominal radiologists for the degree of wall thickening, location and length of involvement (short, <or = 15 cm; medium, 16-30 cm; or long, >30 cm), presence of hemoperitoneum, and pattern of attenuation. Patency and caliber of the superior mesenteric artery and vein were noted. Diagnosis was confirmed by laboratory findings, clinical parameters, and follow-up examinations, or at surgery. A Mann-Whitney U or Fisher's exact test was used to compare the two conditions for the following features: wall thickening, location and length of involvement, presence of hemoperitoneum, and appearance of the target sign. RESULTS Among the 35 examinations, 18 abnormal segments with intramural hemorrhage and 19 abnormal segments with ischemia were identified. (Two patients with intramural hemorrhage each had two segments involved.) Mean bowel wall thickness was 11.7 mm (range, 4-25 mm) in patients with intramural hemorrhage and 4.0 mm (range, 1-9 mm) in patients with ischemia. Length of involvement was short in 14 segments with intramural hemorrhage and medium in four segments with intramural hemorrhage; none of the segments with intramural hemorrhage had long involvement. Among the segments with ischemia, length of involvement was medium in three and long in 16; none of the ischemic segments had short involvement. Fifteen (94%) of 16 segments with intramural hemorrhage and six (32%) of 19 segments with ischemia had hemoperitoneum. Seven of the 18 segments with intramural hemorrhage and nine of the 19 with ischemia had a target sign. Segments with intramural hemorrhage exhibited a higher statistically significant degree of wall thickening (p < 0.001), a shorter length of involvement (p < 0.0001), and a higher incidence of hemoperitoneum (p < 0.001) than did segments with ischemia. The two groups were not statistically different in location of involvement (p = 0.12) or in the incidence of the target sign (p = 0.18). CONCLUSION Although some of the CT features overlap, a short segment involvement with wall thickening of 1 cm or greater is typical of intramural hemorrhage; a long segment involvement with wall thickening of less than 1 cm is typical of ischemia.
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Affiliation(s)
- Michael Macari
- Department of Radiology, Abdominal Imaging Section, Tisch Hospital, New York University Medical Center, 560 First Avenue, Ste. HW 207, New York, NY 10016, USA
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Remzi FH, Fazio VW, Oncel M, Baker ME, Church JM, Ooi BS, Connor JT, Preen M, Einstein D. Portal vein thrombi after restorative proctocolectomy. Surgery 2002; 132:655-61; discussion 661-2. [PMID: 12407350 DOI: 10.1067/msy.2002.127689] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Restorative proctocolectomy (RP) has been the surgical procedure of choice for surgical management of mucosal ulcerative colitis since 1978. This study was undertaken to investigate the clinical presentation and implications of portal vein thrombi (PVT). METHODS We reviewed all patients undergoing RP in our institution in the 4 years from January 1997 to December 2000. As the diagnosis of PVT was made on computed tomography (CT) scan in all cases, we confined our incidence estimate to those patients having an abdominal CT scan postoperatively. All scans were reviewed by an experienced radiologist. Patient demographics, symptoms, and clinical course were recorded. RESULTS A total of 702 patients underwent RP, of whom 94 had a CT scan within the postoperative period. PVT was diagnosed in 42 of the 94 patients (45%). PVT was diagnosed at initial reading of the scan in 11 patients, and on review in 31. The indications for CT scan included abdominal pain, fever, leukocytosis, and delayed bowel function. Septic complications of RP caused these symptoms and signs in 45 patients, 20 of whom had PVT. Twenty-two patients were found to have had PVT without evidence of any septic source. CONCLUSION PVT can be found in a high proportion of patients undergoing abdominal CT scan after RP. It is often associated with pain, fever, nausea vomiting, tenderness, and leukocytosis. This study shows that PVT subtle enough to go undiagnosed has no serious consequences, even when not treated. Also, patients treated with anticoagulation recover completely.
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Affiliation(s)
- Feza H Remzi
- Departments of Colorectal Surgery; Radiology; and Biostatistics and Epidemiology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Affiliation(s)
- C Conri
- Service de médecine interne et pathologie vasculaire, hôpital Saint-André, 33800 Bordeaux, France.
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