Mesenteric venous thrombosis

Prostaglandin E-major urinary metabolites as a new biomarker for acute mesenteric ischemia

BACKGROUND

Acute mesenteric ischemia (AMI) is an emergent vascular disease caused by cessation of the blood supply to the small intestine. Despite advances in the diagnosis, intervention, and surgical procedures, AMI remains a life-threatening condition. Prostaglandin E2 major urinary metabolite (PGE-MUM), the urinary metabolite of prostaglandin E2, is known to be stable in urine and has been suggested to be a valuable biomarker for intestinal mucosal inflammation, such as ulcerative colitis. We therefore investigated whether or not PGE-MUM levels reflect the degree of ischemia in an intestinal ischemia-reperfusion model.

METHODS

Male rats were used to establish a superior mesenteric artery occlusion (SMAO) group, in which the superior mesenteric artery was clamped, and a sham group. The clamping times in the SMAO group were either 30 minutes or 60 minutes, and reperfusion times were either 3 hours or 6 hours, after which PGE-MUM values were measured.

RESULTS

The histological injury score of the SMAO (30-minute ischemia and 6-hour reperfusion group, 1.8 ± 0.4; 60-minute ischemia and 6-hour reperfusion group, 4.7 ± 0.5) and were significantly greater than that of the sham group (0.4 ± 0.7, p < 0.05). The PGE-MUM levels in the SMAO group (30-minutes ischemia and 6-hour reperfusion group, 483 ± 256; 60-minutes ischemia and 6-hour reperfusion group, 889 ± 402 ng/mL) were significantly higher than in the sham group (30-minute and 6-hour observation group, 51 ± 20; 60-minute and 6-hour observation group, 73 ± 32 ng/mL; p < 0.05). Furthermore, the PGE-MUM value was corrected by the concentration of urinary creatinine (Cr). The PGE-MUM/urinary Cr levels in the SMAO group were also significantly higher than in the sham group ( p < 0.05).

CONCLUSION

We found that intestinal ischemia-reperfusion increased urinary PGE-MUM levels depending on the ischemic time. This suggests the potential utility of PGE-MUM as a noninvasive marker of intestinal ischemia.

An Atypical Presentation of Dulaglutide-Induced Pancreatitis Complicated by Superior Mesenteric Vein Thrombosis

Glucagon-like peptide 1 (GLP-1) agonists are commonly used in the management of type 2 diabetes due to their glucose-lowering effects and potential cardiovascular benefits. While generally well-tolerated, here we report a unique case associated with GLP-1 therapy. A 57-year-old male with a history of type 2 diabetes developed mild abdominal pain with no nausea or vomiting approximately four months after increasing the dose of GLP-1 therapy. Imaging studies revealed mesenteric vein thrombosis and an enlarged pancreatic head. Endoscopic ultrasound with biopsies was completed, which confirmed acute pancreatitis. The patient was promptly treated with a heparin drip and supportive care. The GLP-1 agonist was discontinued. This case highlights a rare but critical adverse event associated with GLP-1 receptor agonists as well as the importance of considering unusual complications in patients initiating such therapy. Further research is warranted to elucidate the underlying mechanisms and risk factors for these adverse events.

Outcome of laparotomy and conservative treatment of patients with acute mesenteric venous ischemia with viable bowel

BACKGROUND

Acute mesenteric ischemia (AMI) is one of the most serious abdominal emergencies. Predicting the onset of bowel necrosis that warrants surgical intervention is of paramount importance in AMI. The present study aimed to investigate the outcome of patients with AMI secondary to mesenteric venous occlusion (MVO) and the consequence of non-therapeutic exploratory laparotomy.

METHODS

The records of 132 patients with AMI were retrospectively reviewed. The outcome of patients with acute mesenteric venous ischemia (AMVI) and viable bowel was analyzed based on the method of treatment: conservative versus surgical. The impact of non-therapeutic laparotomy on the outcome of patients with AMVI in terms of morbidity, readmission, and mortality was analyzed.

RESULTS

Forty-seven patients (34 male) with AMVI had viable bowel. Of the 47 patients with viable bowel, 8 (17%) had an exploratory non-therapeutic laparotomy, whereas 39 patients were treated conservatively. Patients who had non-therapeutic laparotomy had significantly higher complication (50 vs 5.1%, p = 0.005) and readmission rates (37.5 vs 5.1%, p = 0.03) and longer hospital stay (8.5 vs 7 days, p = 0.02) than those treated conservatively. Patients with bowel necrosis who had a therapeutic laparotomy had slightly lower rates of morbidity and mortality as compared to patients with viable bowel who underwent a non-therapeutic laparotomy.

CONCLUSION

Careful assessment and informed decision-making in patients with AMVI are crucial to avoid unnecessary surgical intervention that can result in higher rates of complications and readmission and extended hospital stay.

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.

Acute management of mesenteric emergencies: Tailoring the solution to the problem

Acute mesenteric ischemia (AMI) constitutes a life-threatening problem that can result in death, multiorgan failure, and severe nutritional disability. Although AMI is a rare cause of acute abdominal emergencies, ranging between 1 and 2 individuals per 10,000, the morbidity and mortality rates are high. Arterial embolic etiology composes nearly one-half of AMIs, with a sudden onset of severe abdominal pain considered the most common symptom. Arterial thrombosis is the second most common cause of AMI, which presents similarly to arterial embolic AMI, although often more severe due to anatomic differences. Veno-occlusive causes of AMI are the third most common and are associated with an insidious onset of vague abdominal pain. Each patient is unique, and the treatment plan should be tailored to their individual needs. This may include considering the patient's age, comorbidities, and overall health, as well as their preferences and personal circumstances. A multidisciplinary approach involving specialists from different fields, such as surgeons, interventional radiologists, and intensivists, is recommended for the best possible outcome. Potential challenges in tailoring an optimal treatment plan for AMI may include delayed diagnosis, limited availability of specialized care, or patient factors that make some interventions less feasible. Addressing these challenges requires a proactive and collaborative approach, with regular review and adjustment of the treatment plan as needed to ensure the best possible outcome for each patient.

Mesenteric venous thrombosis

Mesenteric vein thrombosis (MVT) is a rare condition that can present acutely, subacutely, or chronically. MVT can be isolated or within a splanchnic thrombosis (spleno-porto-mesenteric). Symptomatic cases usually present as nonspecific abdominal pain, with or without signs of intestinal ischemia, and the diagnosis is usually made by imaging test (abdominal CT or MRI) in patients with high clinical suspicion. An early clinical-surgical approach is recommended to screen those patients with warning signs and who benefit from an exploratory laparotomy in addition to anticoagulant treatment, which is the cornerstone of medical treatment. MVT is usually associated with prothrombotic states, with hematological disorders (myeloproliferative syndromes and/or JAK2 gene mutations) being of special clinical relevance. On the other hand, the 5-year survival rate is 70-82% and early overall 30-day mortality from MVT can reach 20-32%.

Review article: Acute superior mesenteric vessel ischaemia: A review of clinical practice and biomarkers

A patient with acute occlusion of the superior mesenteric vessels resulting in superior mesenteric vessel ischaemia (SMVI) who presents to the ED with abdominal pain and unremarkable abdominal examination risks delay in diagnosis and treatment with adverse outcome. A comprehensive literature search was performed, and the evidence was reviewed. To-date, there are no accurate biomarkers of SMVI and so, heightened awareness among ED staff and rapidly actioning diagnostic imaging and surgical referral will help fast-track the patient with SMVI to surgical management. Management of SMVI is challenging and requires ongoing communication. Prompt surgical intervention may help reduce mortality and morbidity in SMVI. SMVI is associated with significant mortality and morbidity. With the lack of accurate biomarkers, diagnosis and management is challenging and requires heightened awareness among ED staff for prompt surgical referral and intervention.

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.

Inferior mesenteric vein thrombosis in the setting of testosterone therapy

Inferior mesenteric vein thrombosis (IMVT) is a rare and potentially lethal complication that can progress to mesenteric ischaemia if left untreated. We report a case of a man in his 70s with a history of polycythaemia vera (PV) with a known negative Janus kinase-2 mutation (JAK2V617) who was started on testosterone therapy 2 months before presenting with left lower quadrant abdominal and flank pain. Evaluation revealed thrombocytosis and IMVT on CT scan. A non-operative approach was deferred for anticoagulation therapy. Within 24 hours, the patient demonstrated significant clinical improvement, and he subsequently made a full recovery. The patient underwent 6 months of anticoagulation therapy with Apixaban. This case documents the first case of IMVT in the setting of PV and testosterone therapy in the literature.

Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery

Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.

Acute mesenteric ischemia secondary to oral contraceptive-induced portomesenteric and splenic vein thrombosis: A case report

BACKGROUND

Mesenteric ischemia represents an uncommon complication of splanchnic vein thrombosis, and it is less infrequently seen in young women using oral contraceptives. Diagnosis is often delayed in the emergency room; thus, surgical intervention may be inevitable and the absence of thrombus regression or collateral circulation may lead to further postoperative ischemia and a fatal outcome.

CASE SUMMARY

We report a 28-year-old female patient on oral contraceptives who presented with acute abdominal pain. Her physical examination findings were not consistent with her symptoms of severe pain and abdominal distention. These findings and her abnormal blood tests raised suspicion of acute mesenteric ischemia (AMI) induced by splanchnic vein thrombosis. Contrast-enhanced abdominal computed tomography revealed ischemia of the small intestine with portomesenteric and splenic vein thrombosis (PMSVT). We treated the case promptly by anticoagulation after diagnosis. We then performed delayed segmental bowel resection after thrombus regression and established collateral circulation guided by collaboration with a multidisciplinary team. The patient had an uneventful postoperative course and was discharged 14 d after surgery and took rivaroxaban orally for 6 mo. In subsequent follow-up to date, the patient has not complained of any other discomfort.

CONCLUSION

AMI induced by PMSVT should be considered in young women who are taking oral contraceptives and have acute abdominal pain. Prompt anticoagulation followed by surgery is an effective treatment strategy.

Outcomes of bowel resection following non-mechanical intestinal obstruction due to mesenteric vein thrombosis in Uganda: A case series

Introduction and importance

Mesenteric venous thrombosis (MVT) is one of the common occlusive causes of compromised bowel perfusion. Contrast-enhanced CT angiography is the diagnostic imaging study of choice for MVT. In-hospital mortality following acute mesenteric infarction is 63 %. Surgical resection may be life saving for patients with peritoneal signs or refractory to conservative management.

Case presentation

We consecutively included records of five patients from Lubaga Hospital with intestinal obstruction who underwent bowel resection following intraoperatively confirmed acute mesenteric ischemia between May 2017 and November 2021. Three of the patients were female. Patients were between 21 and 45 years. One patient had comorbid conditions and an identifiable underlying etiology of polycythemia for MVT. Duration of symptoms ranged from 1 to 11 days. All patients underwent open laparotomy, the length of bowel resection ranged from 77 cm to 600 cm (mean length of 337 cm). Two patients developed short bowel syndrome (SBS) and one patient developed intestinal fistula. There was one in-hospital death due to multi-organ failure.

Clinical discussion

Morbidity and mortality are associated with delay to diagnose the condition. Revascularization is the primary goal, resection of all non-viable regions and preservation of viable bowel. Mortality is commonly related to multi-organ failure. Advanced intensive care and parenteral nutrition have improved survival rates over the years. 2-year and 5-year survival rates have been reported to be 70 % and 50 %.

Conclusion

Good outcomes are still possible for post-operatively optimized patients despite the high mortality and morbidity associated with bowel resection following extensive mesenteric thrombosis.

•

Despite high morbidity and mortality of mesenteric thrombosis, good outcomes are possible in optimized patients.

•

Short bowel syndrome and fistulae are a major course of morbidity in massive bowel resected patients.

•

Surgery is indicated for patients with peritoneal signs and those refractory to conservative management.

A suggestive case report of acute mesenteric venous thrombosis diagnosed at Computed Tomography Angiography

Acute mesenteric venous thrombosis (MVT) is a rare but potentially fatal condition with superior mesenteric vein being the most common site of thrombosis development. It is more common in patients with underlying disorders which cause disruptions to Virchow's Triad of hypercoagulability, stasis and endothelial injury. The disease is often associated with intestinal ischemia in its acute form, further complicating its management. We present a case of acute superior mesenteric venous thrombosis, in a 65 years old man with initial features of intestinal infarction, diagnosed at Computed Tomography Angiography (CTA) scan. However, the patient was stable, with a nonperitonitic abdomen, and was subsequently managed with conservative measures.

Superior mesenteric venous thrombosis in a 47 years old male with protein S deficiency: A case report

Introduction

Mesenteric venous thrombosis is due to blood clot in veins that drain blood from the intestine. It may lead to mesenteric ischemia. Protein S deficiency is one of the causes of superior mesenteric vein thrombosis.

Case presentation

A 47 years old male patient presented with pain in the abdomen. Contrast CECT shows filling defect in the superior mesenteric venous thrombosis. Coagulometer showed lower protein S activity than that of normal.

Clinical discussion

Proper diagnosis is needed for early detection so that proper intervention can be made on time. Anticoagulation and vitamin K antagonists are given.

Conclusions

Though rare, protein S deficiency should be considered a possible cause of mesenteric venous thrombosis.

•

Mesenteric venous thrombosis is one of the causes of mesenteric ischemia which occurs as a result of local blood coagulation impairing the venous return of bowel.

•

Protein C and S are vitamin K dependent glycoprotein deficiency of these proteins leads to thrombosis.

•

CECT is the diagnostic modality for the proper diagnosis which should be done as early, so that proper intervention and treatment can be done in time.

•

aPTT and PT/INR should monitored in time, to identify the risk factors so that lifetime medication can be started early.

Superior mesenteric venous thrombosis: Endovascular management and outcomes

BACKGROUND

Superior mesenteric venous thrombosis (SMVT) is a rare but fatal condition that is typically treated initially with anticoagulation therapy, and if this fails, with endovascular interventions. However, due to its rarity, there are not many studies that have explored the effectiveness of anticoagulation and endovascular therapies in treating SMVT.

AIM

To evaluate patients diagnosed with SMVT who received endovascular therapy in addition to anticoagulation and report technical and clinical outcomes.

METHODS

A retrospective analysis of the patients who underwent endovascular treatment for SMVT at Mayo Clinic from 2000-2019 was performed. Technical success was defined as angiographic improvement in SMV flow after intervention. Primary patency was defined as the interval from reestablishing mesenteric venous flow until the first repeat thrombotic event or need for additional intervention. Secondary patency was defined as successful restoration of flow after repeat intervention until rethrombosis or last follow-up. The adverse events were reported through Clavien-Dindo classification.

RESULTS

Twenty-four patients were included for analysis. The median age at intervention was 60 years (35-74 years) and 16 (67%) were men. Nineteen patients presented with acute thrombosis (79.2%) and 5 with chronic thrombosis with acute manifestations (20.8%). The most commonly used endovascular modalities were thrombectomy in 12 patients (50.0%) and catheter-directed thrombolysis in 10 patients (41.7%). Technical success was achieved in 18 patients (75%). The 14-d and 30-d primary patency rates were 88.9% and 83.3%, respectively. Adverse events were reported in two patients (8.3%), one marked as grade IIIB, and 1 death marked as grade V. Five-year overall survival rate was 82% (58%-100%).

CONCLUSION

Endovascular intervention with anticoagulation appears to be effective for managing SMVT. This treatment combination may be considered as first-line therapy for SMVT management in select patients.

Idiopathic acute superior mesenteric venous thrombosis after renal transplantation: A case report

BACKGROUND

Acute superior mesenteric venous thrombosis (MVT) is a rare condition associated with a high mortality rate. The treatment strategy for MVT is clinically challenging due to its insidious onset and rapid development, especially when accompanied by kidney transplantation.

CASE SUMMARY

Here we present a rare case of acute MVT developed 3 years after renal transplantation. A 49-year-old patient was admitted with acute abdominal pain and diagnosed as MVT with intestinal necrosis. An emergency exploratory laparotomy was performed to remove the infarcted segment of the bowel. Immediate systemic anticoagulation was also initiated. During the treatment, the patient experienced bleeding, anastomotic leakage, and sepsis. However, after aggressive treatment was administered, all thrombi were completely resolved, and the patient recovered with his renal graft function unimpaired.

CONCLUSION

The present case suggests that accurate diagnosis and timely surgical treatment are important to improve the survival rate of MVT patients. Bleeding with anastomotic fistula needs to be treated with caution because of grafts. Also, previously published cases of mesenteric thrombosis after renal transplantation were reviewed.

Recurrent Acute Pancreatitis and Superior Mesenteric Venous Thrombosis - Cause or Course

The management of pancreatitis can be daunting, especially when associated with other comorbidities. These complexities in management are conflicting in the presence of comorbidities with a similar presentation, such as abdominal pain. Acute pancreatitis (AP) has been associated with mesenteric thrombosis but less commonly with superior mesenteric vein thrombosis (SMVT) as a causal or complicating dilemma. This case report describes the careful intrigues and overlaps in presentation. Furthermore, this paper presents a dilemma in that contrast-enhanced computed tomography (CT) may not be recommended in the early stage of diagnosis of AP according to the 2013 American College of Gastroenterology (ACG) guideline, but SMVT, which can be fatal, sometimes, complicates AP, and contrast-enhanced CT is important in its diagnosis. This paper attempts to address this dilemma. Managing these two potentially fatal pathologies requires promptness and thoughtfulness in averting a deadly outcome. Because SMVT is fatal, in this paper, we reiterate the use of contrast-enhanced CT in the early stages of the management of AP. Fatal complications from AP should not be missed. Although contrast-enhanced CT is not recommended in the early stages of diagnosis of AP in the ACG guideline, fatal complications such as SMVT can be avoided.

Complex Syndrome of the Complete Occlusion of the End of the Superior Mesenteric Vein, Opposed with the Stable Gastric Pentadecapeptide BPC 157 in Rats

Background. Gastric pentadecapeptide BPC 157 therapy in rats compensated irremovable occlusion of various vessels and counteracted the consequent multiorgan dysfunction syndromes by activation of the corresponding collateral bypassing loops. Thus, we used BPC 157 therapy against the irremovable occlusion of the end of the superior mesenteric vein. Methods. Assessments, for 30 min (gross recording, venography, ECG, pressure, microscopy, biochemistry, and oxidative stress) include the portal and caval hypertension, aortal hypotension, and centrally, the superior sagittal sinus hypertension, systemic arterial and venous thrombosis, ECG disturbances, MDA-tissue increase, and heart, lung, liver, kidney and gastrointestinal tract, in particular, and brain (cortex (cerebral, cerebellar), hypothalamus/thalamus, hippocampus) lesions. Rats received BPC 157 medication (10 µg/kg, 10 ng/kg) intraperitoneally at 1 or 15 min ligation time. Results. BPC 157 rapidly activated the superior mesenteric vein-inferior anterior pancreati-coduodenal vein-superior anterior pancreaticoduodenal vein-pyloric vein-portal vein pathway, reestablished superior mesenteric vein and portal vein connection and reestablished blood flow. Simultaneously, toward inferior caval vein, an additional pathway appears via the inferior mesenteric vein united with the middle colic vein, throughout its left colic branch to ascertain alternative bypassing blood flow. Consequently, BPC 157 acts peripherally and centrally, and counteracted the intracranial (superior sagittal sinus), portal and caval hypertension, aortal hypotension, ECG disturbances attenuated, abolished progressing venous and arterial thrombosis. Additionally, BPC 157 counteracted multiorgan dysfunction syndrome, heart, lung, liver, kidney and gastrointestinal tract, and brain lesions, and oxidative stress in tissues. Conclusion. BPC 157 therapy may be specific management also for the superior mesenteric vein injuries.

Ischemic bowel disease in 2021

Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.

Successful vascular interventional management of superior mesenteric vein thrombosis in a patient with COVID-19: A case report and review of literature

Coronavirus disease (COVID-19) is associated with thrombosis formation in various vessels, including those in the abdomen. In this case report, we present a COVID-19 infected patient who had developed abdominal discomfort. The patient underwent magnetic resonance imaging, which showed signs of thrombosis formation in the superior mesenteric vein (SMV). After conservative treatment failed, the patient was considered for vascular intervention. The SMV clot underwent thrombolysis via the infusion of reteplase (dose 6 mg stat, followed by 1 mg every hour) through a 5F perfusion Cather (Cragg-McNamara, 20 cm). Control venography showed near-complete recanalization. The patient was discharged with oral anticoagulants. Our case report is one of the first incidents of successful vascular intervention in SMV thrombosis in the setting of COVID-19.

Direct oral anticoagulants for unusual-site venous thromboembolism

Direct oral anticoagulants (DOACs) are currently the preferred oral anticoagulant treatment for most of the patients with deep vein thrombosis of the lower extremities and/or pulmonary embolism. DOACs have several advantages over vitamin K antagonists, such as availability of fixed dosages, fewer drug interactions, faster onset of action, shorter half-life, and lower risk of major and intracranial bleeding. Although the evidence on the use of DOACs in patients with unusual-site venous thromboembolism (VTE) is limited to a few, small randomized controlled trials, these drugs are increasingly used in clinical practice, and several observational cohort studies have been published recently. This narrative review will describe the latest evidence for the use of the DOACs in patients with thrombosis in atypical locations (splanchnic, cerebral, upper extremity, ovarian, and renal vein thrombosis) and will provide some practical advice for their use in patients with unusual-site VTE.

Early transcatheter thrombectomy and thrombolytic therapy in acute non-cirrhotic and non-malignant mesenteric vein thrombosis: Case report of two cases and literature review

•

Non-cirrhotic non malignant acute mescenteric thrombosis could lead to massive bowel ischaemia and is challenging to manage.

•

Conventional PV or SMV exploration is associated with significant blood lost, physiological disturbances and may need repeated procedures.

•

Catheter directed thrombolysis and thrombectomy provide minimal invasive option to restore patency of PV or SMV.

•

Literature review found high success rate and favourable outcome.

•

Catheter directed therapy should be the first line therapy.

Aim

To present two cases of acute non-cirrhotic and non-malignant mesenteric vein thrombosis (MVT) treated with early transcatheter thrombectomy and thrombolysis with tissue plasminogen activator (tPA) and to review the literature on transcatheter thrombectomy and thrombolytic therapy of such condition.

Methods

Two cases of acute MVT treated with transhepatic transcatheter thrombectomy and thrombolysis in addition to systemic anticoagulation upon diagnosis are presented. In addition, a Pubmed literature search was undertaken using keywords acute mesenteric vein thrombosis, thrombolysis and thrombectomy. The inclusion criteria were studies examining the impacts of transcatheter thrombolysis and thrombectomy in the management of acute MVT.

Results

Early transcatheter thrombectomy and thrombolysis achieves technical success in both patients and result in nearly complete recanalization of the venous system, with no recurrent thrombosis to date in follow up. Both patients do not require extensive bowel resection despite extensive thrombus on presentation. However, both patients develop intra-abdominal bleeding requiring blood transfusion and embolization of the transcatheter tract.

Conclusion

Catheter-directed first approach provides a minimal invasive approach for management of non-malignant and non-cirrhotic acute mesenteric thrombosis. It offers the benefits of rapid venous recanalization and avoid massing bowel resection despite extensive thrombosis. Subsequent progression into chronic MVT was also reduced. However, the procedure could lead to bleeding from puncture site and hence embolization of the catheter tract is advised during catheter removal.

Venous thrombosis of the liver: current and emerging concepts in management

Venous thrombosis within the hepatic vasculature is associated with a distinct array of risk factors, characteristics, and potential complication. As such, it entails unique management considerations and strategies relative to the more common categories of venous thromboembolic disease. Although broadly divided into thrombosis of the afferent vasculature (the portal venous system) and efferent vasculature (the hepatic venous system), presentations and management strategies within these groupings are heterogeneous. Management decisions are influenced by a variety of factors including the chronicity, extent, and etiology of thrombosis. In this review we examine both portal vein thrombosis and hepatic vein thrombosis (and the associated Budd-Chiari Syndrome). We consider those factors which most impact presentation and most influence treatment. In so doing, we see how the particulars of specific cases introduce nuance into clinical decisions. At the same time we attempt to organize our understanding of such cases to help facilitate a more systematic approach. Critically, we must recognize that although increasing evidence is emerging to help guide our management strategies, the available data remain limited and largely retrospective. Indeed, current paradigms are based largely on observational experiences and expert consensus. As new and more rigorous studies emerge, treatment strategies are likely to be continually refined, and paradigm shifts are sure to occur.

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.

Idiopathic acute mesenteric venous thrombosis causing ischemic enteritis: A case report

•

Acute MVT is frequently idiopathic in origin. These cases require indefinite outpatient anticoagulation.

•

MVT results in bowel infarction less frequently than arterial thrombosis, though life-threatening infarction is possible.

•

Infarction is more common with thrombosis of smaller, more distal mesenteric veins.

•

Contrast-enhanced [[1], [2], [3], [4], [5], [6], [7], [8]] CT is the preferred diagnostic modality for MVT; lab tests are used to explore ischemia and peritonitis.

•

CT findings include venous filling defect, hypoattenuated bowel wall thickening, halo sign, and mesenteric edema.

Introduction

Though mesenteric venous thrombosis (MVT) causes bowel ischemia far less frequently than arterial thrombosis, it still has the potential to cause life-threatening bowel infarction.

Presentation of case

Presented here is a case of idiopathic MVT of the superior mesenteric vein and multiple distal venous branches causing diffuse peritonitis secondary to small bowel infarction in a 64 year old male. History and physical exam demonstrated severe persistent abdominal pain, hematochezia, and diffuse abdominal tenderness to palpation with guarding. Venous filling defects and segmental enteritis were noted on CT. The patient was treated with immediate IV heparin therapy with subsequent laparotomy and excision of 45 cm of ischemic ileum. The patient had an uncomplicated recovery. Post-operative thrombophilia screen was negative. The patient was discharged on indefinite warfarin therapy.

Discussion

MVT is often idiopathic in nature, with up to 49% having no identifiable cause. Risk factors include abdominal inflammation and systemic thrombophilias. Importantly, bowel infarction is more common with occlusion of more distal, smaller caliber mesenteric vessels. The standard of diagnosis is contrast-enhanced abdominal CT, and management is prompt anticoagulation with surgical intervention if severe. If the cause remains unclear, outpatient anticoagulation is continued indefinitely.

Conclusion

This case provides a valuable demonstration of several important MVT concepts – specifically the high rate of idiopathic etiology, the need for indefinite anticoagulation in idiopathic cases, and the increased risk of infarction in occlusion of smaller, more distal mesenteric veins.

Management of superior mesenteric venous thrombus in cystic fibrosis related liver disease

Abdominal pain is a common feature in patients with cystic fibrosis (CF) and CF related liver disease (CFLD). Superior mesenteric venous (SMV) thrombosis is an uncommon but important cause of abdominal pain. Management strategies are complicated by an underlying prothrombotic state and increased risk of bleeding from complications of CF and CFLD. This review addresses clinical presentation, detection and management options of an acute SMV thrombus in the context of CF.

Predictors of bowel necrosis in patients with acute mesenteric ischemia: systematic review and meta-analysis

Acute mesenteric ischemia (AMI) is a serious medical condition that can progress to transmural bowel necrosis. Prediction of the onset of bowel necrosis in AMI is crucial to justify surgical intervention before more severe consequences supervene. This systematic review aimed to identify the significant predictors of bowel necrosis in AMI in the current literature. In adherence to the PRISMA guidelines, electronic databases were searched for studies that reported significant independent predictors of bowel necrosis in AMI. The quality of the studies was assessed with MINORS score. The main outcomes of the review were the incidence and predictors of bowel necrosis in patients with AMI and the mortality rate. This systematic review comprised nine articles that included 963 patients of a median age of 57 years. Irreversible bowel necrosis was found in 402 (41.7%) patients. The significant predictors of bowel necrosis were subdivided into eight clinical, seven biochemical, and six radiologic parameters. Eight parameters were reported by two or more studies, whereas 13 were reported by a single study. Based on the weight and odds ratio of the predictive parameters, a prognostic scoring system, Emile-Khan Score, was proposed. Several clinical, biochemical, and radiologic predictors of bowel necrosis were reported in the literature. Pooling of odds ratios was feasible for eight factors that were reported by more than one study. Further studies are needed to ascertain the utility of the other predictive factors.Level of evidence: Level II (systematic review and meta-analysis).

Diagnoses and Difficulties in Mesenteric Pathology

Mesenteric diseases are broadly separated into 2 groups: non-neoplastic and neoplastic. Common non-neoplastic mesenteric diseases include those involving the mesenteric vasculature and those of inflammatory processes. Mesenteric inflammatory processes can mimic a neoplastic process. Neoplastic diseases of the mesentery are rare. Generally, the morphology, behavior and diagnostic criteria for mesenteric tumors are similar to their soft tissue or organ-specific counterparts. Their recognition can be challenging because they sometimes are overlooked in differential diagnoses.

Laparoscopic surgery in patients with interstitial lung disease: A single-center retrospective observational cohort study

INTRODUCTION

Laparoscopic surgery requiring longer operative times and artificial pneumoperitoneum may affect pulmonary function; its feasibility in patients with interstitial lung disease remains unknown. Therefore, we examined the feasibility of laparoscopic surgery in patients with interstitial lung disease.

METHODS

We conducted a retrospective observational cohort study and examined the clinical data of patients with interstitial lung disease who had undergone abdominal surgery under general anesthesia. The primary end-point was the incidence of pulmonary complications. The secondary end-points were non-pulmonary complications and in-hospital mortality.

RESULTS

Twenty-nine patients who had undergone abdominal surgery were diagnosed with interstitial lung disease after a review of their clinical and imaging records. Laparoscopic surgery and open surgery were performed in 11 and 18 patients, respectively. Acute exacerbation occurred in one (9%) patient in the laparoscopic group and three patients (17%) in the open group; all had undergone emergency surgery. Postoperative pneumonia did not occur in any patients. Non-pulmonary complications occurred in one patient (9%) in the laparoscopic group and two patients (11%) in the open group. One patient in each group died of acute exacerbation during hospitalization.

CONCLUSION

Neither acute exacerbation nor pulmonary complications occurred after elective laparoscopic or open surgery in patients with interstitial lung disease. The risk of acute exacerbation after elective laparoscopic surgery may not be as high as that after elective thoracic surgery.

Portal Venous Thrombosis Associated with Use of Etonogestrel/ethinyl Estradiol Vaginal Ring

Introduction

Portal venous thrombosis is a life-threatening cause of abdominal pain. In younger patients, heritable thrombophilias, pregnancy, tobacco use, and oral contraceptives are associated.

Case Report

A 26-year-old woman prescribed contraceptive vaginal ring presented with abdominal pain and was diagnosed with an extensive portal venous thrombosis. Management included heparin and later an oral anticoagulant with good short-term outcome.

Discussion

Women using hormonal contraception are approximately four times more likely to develop thromboembolism. Risk of thromboembolism is similar between users of intravaginal and oral contraceptives.

Conclusion

Portal venous thrombosis must be considered in women presenting with abdominal pain who are prescribed hormonal contraceptives, including intravaginal forms.

Review Article: Mesenteric Ischemia

PURPOSE OF REVIEW

Mesenteric ischemia (MI), both acute (AMI) and chronic (CMI), is a challenging diagnosis to make, and early diagnosis and treatment are vital to improve outcomes. This manuscript summarizes the most up to date information on diagnosis and treatment of these disorders.

RECENT FINDINGS

There have been several significant advancements in the computed tomography (CT) diagnostic imaging as well as medical and endovascular management of AMI and CMI. In appropriate populations, endovascular interventions appear superior to open surgical management with lower mortality, morbidity, and cost of care. Efficient clinical identification and targeted testing are essential to diagnose AMI and CMI. Aggressive resuscitation and early endovascular (or in select cases, surgical) intervention improve outcomes in those with AMI. In those with CMI, considering this on the differential diagnosis and imaging appropriately can identify those that might benefit from intervention and halt progression to acute episodes.

Cerebral and Splanchnic Vein Thrombosis: Advances, Challenges, and Unanswered Questions

Cerebral vein thrombosis (CVT) and splanchnic vein thrombosis (SVT) are two manifestations of venous thromboembolism (VTE) at unusual sites. They have an incidence at least 25-50 times lower than usual site VTE, but represent true clinical challenges. Recent evidence on the epidemiology, risk factors, prognosis, and treatment of CVT and SVT has been published in the last two decades, thus contributing to a better understanding of these diseases. The improvement in imaging techniques and a higher degree of clinical suspicion may have led to the observed increased frequency, whereas a better knowledge of provoking mechanisms could have contributed to reducing the proportion of events classified as unprovoked or idiopathic (13%-21% of CVT, 15%-27% of SVT). Few small randomized clinical trials and a number of observational studies, although hampered by heterogeneous therapeutic approaches, shed light on the safety and effectiveness of anticoagulant therapy in these populations. However, there are still some grey areas that warrant future research. In this narrative review, we discuss recent advances and therapeutic challenges in CVT and SVT.

Modifying ICCA with Trp-Phe-Phe to Enhance in vivo Activity and Form Nano-Medicine

BACKGROUND

1-(4-isopropylphenyl)-β-carboline-3-carboxylic acid (ICCA) was modified by Trp-Phe-Phe to form 1-(4-isopropylphenyl)-β-carboline-3-carbonyl-Trp-Phe-Phe (ICCA-WFF).

PURPOSE

The object of preparing ICCA-WFF was to enhance the in vivo efficacy of ICCA, to explore the possible targeting action, and to visualize the nano-feature.

METHODS

The advantages of ICCA-WFF over ICCA were demonstrated by a series of in vivo assays, such as anti-tumor assay, anti-arterial thrombosis assay, anti-venous thrombosis assay, P-selectin expression assay, and GPIIb/IIIa expression assay. The nano-features of ICCA-WFF were visualized by TEM, SEM and AFM images. The thrombus targeting and tumor-targeting actions were evidenced by FT-MS spectrum analysis.

RESULTS

The minimal effective dose of ICCA-WFF slowing tumor growth and inhibiting thrombosis was 10-fold lower than that of ICCA. ICCA-WFF, but not ICCA, formed nano-particles capable of safe delivery in blood circulation. In vivo ICCA-WFF, but not ICCA, can target thrombus and tumor. In thrombus and tumor, ICCA-WFF released Trp-Phe-Phe and/or ICCA.

CONCLUSION

Modifying ICCA with Trp-Phe-Phe successfully enhanced the anti-tumor activity, improved the anti-thrombotic action, formed nano-particles, targeted tumor tissue and thrombus, and provided an oligopeptide modification strategy for heterocyclic compounds.

Upper gastrointestinal bleeding in superior mesenteric vein thrombosis

Superior mesenteric vein thrombosis (SMVT) is an uncommon disorder with non-specific signs and symptoms, where missed catastrophic consequences often follow secondary to disease progression. This case report highlights an unusual complication of SMVT and presented alongside with literature review.

Case series: Portomesenteric venous thrombosis complicating laparoscopic bariatric procedures

•

Portomesenteric vein thrombosis is a rare but potentially fatal complication of bariatric surgery.

•

Portomesenteric venous thrombosis complicated 3 of 1030 cases (0.29%).

•

Management is primarily with anticoagulants, but surgery is required if the patient shows signs of sepsis.

•

A high index of suspicion, early diagnosis and subsequent adequate management is required.

Introduction

Portomesenteric vein thrombosis is a rare but documented complication of laparoscopic surgery. This rare complication is currently being encountered more frequently with the increase in the rates of laparoscopic bariatric surgery procedures being performed worldwide.

Methods

A retrospective analysis was performed on all bariatric procedures performed in our center between July 2012 & December 2017 to identify cases complicated by portomesenteric venous thrombosis. The cases were compared in terms of operative details, patient presentation, diagnosis, patient risk factors for developing thrombosis, demographics and thrombophilia analysis & subsequent treatment and prognosis.

Results

A total of 1030 bariatric procedures were performed between July 2012 & December 2017. Portomesenteric venous thrombosis complicated 3 of these cases (0.29%). Two of these cases had underwent a laparoscopic sleeve gastrectomy while the third had underwent a gastric band removal and a conversion to a single anastomosis gastric bypass. Amongst these patients, 2 were female while 1 was male with an average BMI 38.9 kg/m². Only one of these patients was a smoker while none of them tested positive for thrombophilias. The diagnosis of portomesenteric venous thrombosis was confirmed with a contrast CT of the abdomen as all patients were re-admitted between 4–20 days post operatively after being discharged on postoperative day 2. All three cases were managed with systemic anticoagulants and none underwent invasive procedures or were re-explored surgically. All were subsequently discharged in good condition.

Conclusion

Portomesenteric venous thrombosis is an uncommon yet potentially fatal complication of bariatric surgery. A high index of suspicion, early diagnosis and subsequent adequate management is required. Based on this case series and the potential risk of portomesenteric venous thrombosis, we altered our clinical practice to include a 1 week course of low molecular weight heparin to be administered to all patients after discharge.

D-dimer: Preanalytical, analytical, postanalytical variables, and clinical applications

D-dimer is a soluble fibrin degradation product deriving from the plasmin-mediated degradation of cross-linked fibrin. D-dimer can hence be considered a biomarker of activation of coagulation and fibrinolysis, and it is routinely used for ruling out venous thromboembolism (VTE). D-dimer is increasingly used to assess the risk of VTE recurrence and to help define the optimal duration of anticoagulation treatment in patients with VTE, for diagnosing disseminated intravascular coagulation, and for screening medical patients at increased risk of VTE. This review is aimed at (1) revising the definition of D-dimer; (2) discussing preanalytical variables affecting the measurement of D-dimer; (3) reviewing and comparing assay performance and some postanalytical variables (e.g. different units and age-adjusted cutoffs); and (4) discussing the use of D-dimer measurement across different clinical settings.

Current knowledge in pathophysiology and management of Budd-Chiari syndrome and non-cirrhotic non-tumoral splanchnic vein thrombosis

Budd-Chiari syndrome and non-cirrhotic non-tumoral portal vein thrombosis are 2 rare disorders, with several similarities that are categorized under the term splanchnic vein thrombosis. Both disorders are frequently associated with an underlying prothrombotic disorder. They can cause severe portal hypertension and usually affect young patients, negatively influencing life expectancy when the diagnosis and treatment are not performed at an early stage. Yet, they have specific features that require individual consideration. The current review will focus on the available knowledge on pathophysiology, diagnosis and management of both entities.

Thrombosis in Children: Approach to Anatomic Risks, Thrombophilia, Prevention, and Treatment

Pediatric venous thromboembolism (VTE) is increasing in incidence but minimal data exist for best practices regarding therapy, use of thrombophilia testing, and management of long-term complications. Classification schema use anatomic location and presence of clinical or thrombophilic inciting factors. There are a small number of risk-assessment and risk-modeling systems for incident VTE, but all suffer from low numbers, single-institution design, and lack of prospective validation. Acute treatment is limited to heparin products and thrombolysis may be indicated in specific situations. In addition, chronic postthrombotic comorbidities are expected to increase in incidence and lack evidence-based treatment paradigms.