Improved Prognosis and Low Failure Rate with Anticoagulation as First-Line Therapy in Mesenteric Venous Thrombosis

Idiopathic superior mesenteric venous thrombosis requiring bowel resection: a report of four cases

BACKGROUND

Superior mesenteric venous thrombosis (SMVT) is mostly treated with anticoagulation therapy; however, SMVT can lead to irreversible bowel ischemia and require bowel resection in the acute or subacute phase.

CASE PRESENTATION

We report four cases of SMVT that required careful observation and bowel resection. Case 1: A 71-year-old man presented with abdominal pain, diarrhea, and vomiting that showed a completely occluded SMV with thrombus and small bowel ischemia. Case 2: A 47-year-old man presented with abdominal pain, peritoneal irritation symptoms, and a completely occluded SMV with thrombus, ischemia of the small bowel, and massive ascites. Case 3: A 68-year-old man presented with abdominal pain and vomiting for several days and showed a partially occluded SMV with a thrombus, bowel ischemia, and massive ascites. Case 4: A 68-year-old man presented with acute abdominal pain and a partially occluded SMV with thrombus and bowel edema without ischemic changes. Anticoagulation therapy was administered; however, 3 days later, abdominal pain and bowel ischemia worsened. Bowel resection was performed in all cases.

CONCLUSIONS

Most idiopathic SMVT cases can be treated with anticoagulation therapy or endovascular thrombectomy. However, in cases with peritoneal irritation signs, these treatments may be ineffective, and bowel resection may be required.

Correlation between white blood cell count and intestinal resection in patients with acute mesenteric vein thrombosis

OBJECTIVE

Acute mesenteric vein thrombosis (AMVT) is an acute abdominal disease with onset, rapid progression, and extensive intestinal necrosis that requires immediate surgical resection. The purpose of this study was to determine the risk factors for nosocomial intestinal resection in patients with AMVT.

METHODS

We retrospectively analysed 64 patients with AMVT diagnosed by CTA at the Affiliated Hospital of Kunming University of Science and Technology from January 2013 to December 2021. We compared patients who underwent intestinal resection (42 patients) with those who did not undergo intestinal resection (22 patients). The area under the ROC curve was evaluated, and a forest map was drawn.

RESULTS

Among the 64 patients, 6 (9.38%) had a fever, 60 (93.75%) had abdominal pain, 9 (14.06%) had a history of diabetes, 8 (12.5%) had a history of deep vein thrombosis (DVT), and 25 (39.06%) had ascites suggested by B ultrasound or CT after admission. The mean age of all patients was 49.86 ± 16.25 years. The mean age of the patients in the enterectomy group was 47.71 ± 16.20 years. The mean age of the patients in the conservative treatment group (without enterectomy) was 53.95 ± 15.90 years. In the univariate analysis, there were statistically significant differences in leukocyte count (P = 0.003), neutrophil count (P = 0.001), AST (P = 0.048), total bilirubin (P = 0.047), fibrinogen (P = 0.022) and DD2 (P = 0.024) between the two groups. The multivariate logistic regression analysis showed that admission white blood cell count (OR = 1.153, 95% CI: 1.039-1.280, P = 0.007) was an independent risk factor for intestinal resection in patients with AMVT. The ROC curve showed that the white blood cell count (AUC = 0.759 95% CI: 0.620-0.897; P = 0.001; optimal threshold: 7.815; sensitivity: 0.881; specificity: 0.636) had good predictive value for emergency enterectomy for AMVT.

CONCLUSIONS

Among patients with AMVT, patients with a higher white blood cell count at admission were more likely to have intestinal necrosis and require emergency enterectomy. This study is helpful for clinicians to accurately determine whether emergency intestinal resection is needed in patients with AMVT after admission, prevent further intestinal necrosis, and improve the prognosis of patients.

Fusobacterium bacteremia presenting with inferior mesenteric vein thrombosis

Isolated mesenteric vein thrombosis associated with Fusobacterium is rare. Physicians should be aware regarding the association of Fusobacterium with thrombosis at various sites.

Nonobstetric Surgical Emergencies in Pregnancy

In this article, we discuss the major nonobstetric surgical complications that may occur in pregnancy. We highlight specific diagnostic challenges particularly with imaging modalities and radiation considerations for the fetus. Topics covered in this article include appendicitis, intestinal obstruction, gallstone disease, hepatic rupture, perforated peptic ulcer, mesenteric venous thrombosis, splenic artery aneurysm rupture, and aortic dissection.

Rare, Overlooked, or Underappreciated Causes of Recurrent Abdominal Pain: A Primer for Gastroenterologists

Recurrent abdominal pain is a common reason for repeated visits to outpatient clinics and emergency departments, reflecting a substantial unmet need for timely and accurate diagnosis. A lack of awareness of some of the rarer causes of recurrent abdominal pain may impede diagnosis and delay effective management. This article identifies some of the key rare but diagnosable causes that are frequently missed by gastroenterologists and provides expert recommendations to support recognition, diagnosis, and management with the ultimate aim of improving patient outcomes.

Incidence and outcomes of acute mesenteric ischaemia: a systematic review and meta-analysis

OBJECTIVE

To estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (Ovid), Web of Science, Scopus and Cochrane Library were searched until 26 July 2022.

ELIGIBILITY CRITERIA

Studies reporting data on the incidence and outcomes of AMI in adult populations.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment with modified Newcastle-Ottawa scale were performed using predeveloped standard forms. The outcomes were the incidence of AMI and its different forms in the general population and in patients admitted to hospital, and the mortality of AMI in its different forms.

RESULTS

From 3064 records, 335 full texts were reviewed and 163 included in the quantitative analysis. The mean incidence of AMI was 6.2 (95% CI 1.9 to 12.9) per 100 000 person years. On average 5.0 (95% CI 3.3 to 7.1) of 10 000 hospital admissions were due to AMI. Occlusive arterial AMI was the most common form constituting 68.6% (95% CI 63.7 to 73.2) of all AMI cases, with similar proportions of embolism and thrombosis.Overall short-term mortality (in-hospital or within 30 days) of AMI was 59.6% (95% CI 55.5 to 63.6), being 68.7% (95% CI 60.8 to 74.9) in patients treated before the year 2000 and 55.0% (95% CI 45.5 to 64.1) in patients treated from 2000 onwards (p<0.05). The mid/long-term mortality of AMI was 68.2% (95% CI 60.7 to 74.9). Mortality due to mesenteric venous thrombosis was 24.6% (95% CI 17.0 to 32.9) and of non-occlusive mesenteric ischaemia 58.4% (95% CI 48.6 to 67.7). The short-term mortality of revascularised occlusive arterial AMI was 33.9% (95% CI 30.7 to 37.4).

CONCLUSIONS

In adult patients, AMI is a rarely diagnosed condition with high mortality, although with improvement of treatment results over the last decades. Two thirds of AMI cases are of occlusive arterial origin with potential for better survival if revascularised.

PROSPERO REGISTRATION NUMBER

CRD42021247148.

Clots in unusual places: lots of stress, limited data, critical decisions

Although much less common than deep vein thrombosis of the lower extremities or lungs, clots in unusual locations, including the splanchnic, cerebral, retinal, upper-extremity, and renal locations, present with significant morbidity and mortality. In the last 2 decades, treatment of clots in these unusual locations is primarily managed medically, with interventional and surgical approaches reserved for more severe or refractory cases. The hematologist is well positioned to provide consultation to organ-specific specialties (ie, neurosurgery, hepatology, ophthalmology), especially because acquired and congenital hypercoagulability plays a major role, and anticoagulation is often the primary treatment. Historically, treatment has been based on expert opinion, but systematic reviews and meta-analyses have recently been published. Various societies have produced guidelines for the treatment of clots in unusual locations; however, randomized clinical trial data remain scarce. In the last few years, increasing data have emerged concerning the efficacy of the direct oral anticoagulants in treating clots in unusual locations. Cases have recently been described highlighting atypical thrombosis associated with COVID-19 infection as well as with the ChAdOx1 nCoV-19 (AstraZeneca) vaccine and Johnson and Johnson's Janssen Ad26.COV2.S vaccine. This article reviews clots in unusual locations with an emphasis on the splanchnic (mesenteric, portal, splenic, hepatic) and cerebral circulation. Through a case-based approach, key questions are posed, and data are presented to help guide diagnosis and treatment.

Patient Outcomes in Mesenteric Venous Thrombosis Treated With Empiric Antibiotics

BACKGROUND

Mesenteric venous thrombosis (MVT) is typically associated with poor prognosis. Although prophylactic antibiotics are sometimes given with the intent of limiting bacterial luminal load and translocation in patients with MVT, this approach has not been universally adopted. The aim of this study is to analyze whether utilizing antibiotics empirically in those with MVT improves patient outcomes and survival when compared to those who do not receive empiric antibiotics.

METHODS

A retrospective review of patients admitted with MVT between 2002 and 2019 at a single academic institution was performed. Demographics and rates of mortality need for bowel resection, readmission, and Clostridium difficile (C. diff) infection were compared between patients treated with empiric antibiotics and patients not treated with antibiotics.

RESULTS

Eighty-three patients (mean age 64.5 years and 55.4% male) who were admitted for MVT were included. Empiric antibiotics were utilized in 53% (n = 44) of MVT patients while 47% (n = 39) received supportive treatment without empiric antibiotics. Death occurred in 4 patients treated with antibiotics and 6 patients treated without antibiotics (9.1% vs. 15.3%, P = .50). Readmissions occurred in 12 patients (27.3%) treated with antibiotics and 10 patients (25.6%) not treated with antibiotics (27.3% vs. 25.6%, P = .87). C. diff infection occurred in 6 patients treated with antibiotics and in no patients not treated with antibiotics (13.6% vs. 0%, P = .03).

CONCLUSIONS

Empiric antibiotic usage may not improve rates of mortality or hospital readmission in patients with MVT and may unnecessarily expose patients to an increased risk of C. diff infection.

Management of Acute Mesenteric Venous Thrombosis: A Systematic Review of Contemporary Studies

Background and Aims:

Acute mesenteric venous thrombosis accounts for up to 20% of all patients with acute mesenteric ischemia in high-income countries. Acute mesenteric venous thrombosis is nowadays relatively more often diagnosed with intravenous contrast-enhanced computed tomography in the portal phase than at explorative laparotomy No high-quality comparative studies between anticoagulation alone, endovascular therapy, or surgery exists. The aim of the present systematic review was to offer a contemporary overview on management.

Materials and Methods:

Eleven relevant published original studies with series of at least ten patients were retrieved from a Pub Med search between 2015 and 2020 using the Medical Subject Heading term “mesenteric venous thrombosis.”

Results:

When MVT is diagnosed early, immediate anticoagulation with either unfractionated heparin or subcutaneous low-molecular-weight heparin should commence. Surgeons need to be aware of the importance to scrutinize the computed tomography images themselves for assessment of secondary intestinal abnormalities to mesenteric venous thrombosis and the risk of bowel resection and worse prognosis. Progression toward peritonitis is an indication for explorative laparotomy and assessment of bowel viability. Frank transmural small bowel necrosis should be resected and bowel anastomosis may be delayed for several days until second look. Meanwhile, intravenous full-dose unfractionated heparin should be given at the end of the first operation. Postoperative major intra-abdominal or gastrointestinal bleeding occurs rarely, but the heparin effect can instantaneously be reversed by protamine sulfate. Patients who do not improve during conservative therapy with anticoagulation alone but without developing peritonitis may be subjected to endovascular therapy in expert centers. When the patient’s intestinal function has recovered, with or without bowel resection, switch from parenteral unfractionated heparin or low-molecular-weight heparin therapy to oral anticoagulation can be performed. There is a trend that direct oral anticoagulants are increasingly used instead of vitamin K antagonists. Up to now, direct oral anticoagulants have been shown to be equally effective with the same rate of bleeding complications. Patients with no strong permanent trigger factor for mesenteric venous thrombosis such as intra-abdominal cancer should undergo blood screening for inherited and acquired thrombophilia.

Conclusion:

Early diagnosis with emergency computed tomography with intravenous contrast-enhancement and imaging in the portal phase and anticoagulation therapy is necessary to be able to have a succesful non-operative succesful course.

Superior Mesenteric Vein Thrombosis in the Setting of Ileitis: Case Report and Literature Review

Acute mesenteric vein thrombosis represents a rare but potentially lethal thrombotic event. Its treatment involves prompt and aggressive anticoagulation therapy. In the perioperative setting, management of the underlying thrombus must be weighed carefully against the risk of bleeding. We describe a 57-year-old man who presented with abdominal pain and was found to have terminal ileitis with concomitant superior mesenteric vein thrombosis.