Mesenteric venous thrombosis

Clostridium paraputrificum Bacteremia and Ectopic Ileal Varices in Underlying Chronic Portal and Superior Mesenteric Vein Thrombosis: Report of a Rare Case

Ischemic bowel disease is considered a high-risk factor for infection from anaerobic bacteria, as the ischemic bowel is the perfect ground for their development. Herein, we present the case of an advance stage colon cancer patient with a rare cause of gastrointestinal bleeding and bacteremia due to Clostridium paraputrificum, a rare anaerobic Gram-positive bacterium. The patient had presented with several episodes of hematochezia in the context of chronic superior mesenteric-portal vein tumor thrombosis and rupture of ectopic varices, and the bacteremia was an unexpected complication of the bowel ischemia due to a combination of arterial ischemia and venous congestion.

Tofacitinib Is Associated With Increased Risk of Postoperative Venous Thromboembolism in Patients With Ulcerative Colitis

BACKGROUND

In 2019, the Food and Drug Administration issued a black box warning for increased risk of venous thromboembolism in patients with rheumatoid arthritis exposed to tofacitinib. There are limited data regarding postoperative venous thromboembolism risk in patients with ulcerative colitis exposed to tofacitinib.

OBJECTIVE

To assess whether preoperative exposure to tofacitinib is associated with increased odds of postoperative venous thromboembolism.

DESIGN

Retrospective review.

SETTINGS

Tertiary academic medical center.

PATIENTS

Consecutive patients exposed to tofacitinib within 4 weeks before total abdominal colectomy or total proctocolectomy, with or without ileostomy, from 2014 to 2021, matched 1:2 for tofacitinib exposure or no exposure.

INTERVENTION

Tofacitinib exposure versus no exposure.

MAIN OUTCOME MEASURES

Ninety-day postoperative venous thromboembolism rate.

RESULTS

Forty-two patients with tofacitinib exposure and 84 case-matched patients without tofacitinib exposure underwent surgery for medically refractory ulcerative colitis. Nine (22.0%) tofacitinib-exposed patients and 7 (8.5%) unexposed patients were diagnosed with venous thromboembolism within 90 days of surgery. In univariate logistic regression, patients exposed to tofacitinib had 3.01 times increased odds of developing venous thromboembolism within 90 days after surgery compared to unexposed patients ( p = 0.04; 95% CI, 1.03-8.79). Other venous thromboembolism risk factors were not significantly associated with venous thromboembolisms. Venous thromboembolisms in both groups were most commonly portomesenteric vein thromboses (66.7% in the tofacitinib-exposed group and 42.9% in the unexposed group) and were diagnosed at a mean of 23.2 days (range, 3-90 days) postoperatively in the tofacitinib-exposed group and 7.9 days (1-19 days) in the unexposed group. There were no statistically significant differences in location or timing between the 2 groups.

LIMITATIONS

Retrospective nature of the study and associated biases. Reliance on clinically diagnosed venous thromboembolisms may underreport the true incidence rate.

CONCLUSIONS

Tofacitinib exposure before surgery for medically refractory ulcerative colitis is associated with 3 times increased odds of venous thromboembolism compared with patients without tofacitinib exposure. See Video Abstract .

TOFACITINIB SE ASOCIA CON UN MAYOR RIESGO DE TROMBOEMBOLISMO VENOSO POSTOPERATORIO EN PACIENTES CON COLITIS ULCEROSA

ANTECEDENTES:En 2019, la FDA emitió una advertencia de recuadro negro sobre un mayor riesgo de tromboembolismo venoso en pacientes con artritis reumatoide expuestos a tofacitinib. Hay datos limitados sobre el riesgo de tromboembolismo venoso postoperatorio en pacientes con colitis ulcerosa expuestos a tofacitinib.OBJETIVO:Evaluar si la exposición preoperatoria a tofacitinib se asocia con mayores probabilidades de tromboembolismo venoso postoperatorio.DISEÑO:Revisión retrospectiva.LUGARES:Centro médico académico terciario.PACIENTES:Pacientes consecutivos expuestos a tofacitinib dentro de las 4 semanas previas a la colectomía abdominal total o proctocolectomía total, con o sin ileostomía, entre 2014 y 2021, emparejados 1:2 para exposición a tofacitinib o ninguna exposición.INTERVENCIÓN(S):Exposición a tofacitinib versus ninguna exposición.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de tromboembolismo venoso posoperatorio a los 90 días.RESULTADOS:Cuarenta y dos pacientes con exposición a tofacitinib y 84 pacientes de casos similares sin exposición a tofacitinib se sometieron a cirugía por colitis ulcerosa médicamente refractaria. Nueve (22,0%) pacientes expuestos a tofacitinib y 7 (8,5%) pacientes no expuestos fueron diagnosticados con tromboembolismo venoso dentro de los 90 días posteriores a la cirugía. En la regresión logística univariada, los pacientes expuestos a tofacitinib tuvieron 3,01 veces más probabilidades de desarrollar un tromboembolismo venoso dentro de los 90 días posteriores a la cirugía en comparación con los no expuestos ( p = 0,04, IC del 95 %: 1,03-8,79). Otros factores de riesgo de tromboembolismo venoso no se asociaron significativamente con el tromboembolismo venoso. Los tromboembolismos venosos en ambos grupos fueron más comúnmente trombosis de la vena portomesentérica (66,7% en los expuestos a tofacitinib y 42,9% en los no expuestos) y se diagnosticaron en una media de 23,2 días (rango, 3-90 días) después de la operación en los expuestos a tofacitinib y 7,9 días. (1-19 días) en los grupos no expuestos, respectivamente. No hubo diferencias estadísticamente significativas en la ubicación o el momento entre los dos grupos.LIMITACIONES:Carácter retrospectivo del estudio y sesgos asociados. La dependencia de tromboembolismos venosos diagnosticados clínicamente puede subestimar la tasa de incidencia real.CONCLUSIONES:La exposición a tofacitinib antes de la cirugía para la colitis ulcerosa médicamente refractaria se asocia con probabilidades 3 veces mayores de tromboembolismo venoso en comparación con los pacientes sin exposición a tofacitinib. (Traducción-Dr. Mauricio Santamaria ).

Fatal pulmonary embolism after surgery for small intestinal necrosis caused by idiopathic portal vein thrombosis: a case report

BACKGROUND

Portal vein thrombosis (PVT) and venous thromboembolism (VTE) both result from partial or complete occlusion of a blood vessel by a blood clot. The prognosis of PVT is generally good; however, PVT with VTE, including pulmonary embolism (PE), has a high mortality rate. We report here a case of PE after surgery for small intestinal necrosis caused by idiopathic PVT.

CASE PRESENTATION

A 69-year-old female attended our hospital with a chief complaint of upper abdominal discomfort, and was diagnosed with necrosis of the small intestine as a result of unexplained PVT. She underwent partial resection of the small intestine. On the second postoperative day, she suffered from respiratory distress and went into cardiopulmonary arrest. The patient recovered following cardiopulmonary resuscitation, but PE was detected. Extracorporeal veno-arterial cardiopulmonary resuscitation and anticoagulation therapy were initiated immediately and the thrombus was aspirated as much as possible. Two days later, extracorporeal veno-arterial cardiopulmonary resuscitation was withdrawn and anticoagulation therapy was continued. The patient subsequently recovered with no neurological damage and was discharged on day 26 after the above procedure.

CONCLUSIONS

Idiopathic PVT is often associated with VTE, and a prompt diagnosis and intervention may result in a good prognosis.

Superior mesenteric vein thrombosis due to COVID-19 vaccination: a case report

BACKGROUND

The worldwide vaccination response to COVID-19 has been associated with rare thrombotic complications, including the case of postvaccination splanchnic venous thrombosis we report here.

CASE PRESENTATION

An 80-year-old Japanese male with abdominal pain presented to our hospital six days after receiving a dose of the COVID-19 messenger ribonucleic acid vaccine. Abdominal computed tomography showed localized edema of the small intestine, increased density of the surrounding adipose tissue, and a thrombus in the superior mesenteric vein. Conservative inpatient treatment with unfractionated heparin relieved the thrombosis, and the patient is currently receiving oral apixaban as an outpatient.

CONCLUSION

Reported cases of thrombosis after COVID-19 vaccination typically have been associated with viral vector vaccines, with few reports of thrombosis induced by mRNA vaccines. The potential for venous thrombosis should be explored when patients present with abdominal pain soon after COVID-19 vaccination.

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.

Acute portal vein thrombosis in an isolated, blunt, minor liver injury near the porta hepatis

Portal vein thrombosis (PVT) secondary to blunt abdominal trauma associated with liver injury is extremely rare in healthy individuals as well as in minor liver injury, and it carries a high rate of morbidity and mortality. Moreover, acute asymptomatic PVT is difficult to diagnose. We present a young trauma patient with isolated minor liver injury associated with acute PVT. A 27-year-old man presented to the emergency department after a motor vehicle collision. His primary survey findings were unremarkable. His secondary survey showed a large contusion (7 cm × 7 cm) at the epigastrium with marked tenderness and localized guarding. The CT angiography of the whole abdomen revealed liver injury grade 3 in hepatic segments 2/3 and 4b (according to the American Association for the Surgery of Trauma classification) extending near the porta hepatis with patent hepatic and portal veins and without other solid organ injury. The follow-up CT of the whole abdomen on post-injury day 7 showed a 1.8-cm thrombus in the left portal vein with patent right portal and hepatic veins, and a decreased size of the hepatic lacerations. A liver function test was repeated on post-injury day 4, and it revealed improved transaminitis. The patient received intravenous anticoagulant therapy with low-molecular-weight heparin according to weight-based dosing for treatment. The CT of the whole abdomen performed 2 weeks after anticoagulant therapy showed small residual thrombosis in the left portal vein. The patient received intravenous anticoagulant therapy for a total 3 months. On the follow-up visits at 1 month, 2 months, 6 months, and 1 year after the injury, the patients did not have any detectable abnormal symptoms. PVT post-blunt minor liver injury is an extremely rare complication. If the thrombosis is left untreated, serious morbidity and mortality can ensue. However, its diagnosis in asymptomatic patients is still challenging. Periodic imaging is necessary for highly suspected PVT, especially in liver injury with lacerations close to the porta hepatis, even in cases of a minor injury.

A rare complication with superior mesenteric vein thrombosis after laparoscopic sleeve gastrectomy: A case report

Laparoscopic sleeve gastrectomy (LSG) has become a frequent procedure to reduce weight and morbid obesity. The procedure involves laparoscopic resection of more than 75% of the greater curvature of the stomach, resulting in early satiety and neuro-hormonal changes that collectively promote effective weight loss. We present a rare case of complication of superior mesenteric vein thrombosis (SMVT) and splenic vein after LSG, with consequent bowel ischemia that was treated with open laparotomy and appropriate anticoagulation therapy. A 56-year-old obese woman (BMI of 42.5 kg/m²), smoker for 30 years, presented to the emergency department with symptoms such as abdominal pain, fever, nausea and vomiting, 2 weeks after LSG intervention. Her white blood cell count was 15.5 (normal values: 3.8-10.4 × 10³ /µL), while C- reactive protein level was 193 (normal values: 0.0-6.0 mg/L) and her D-Dimer level 4.69 (normal values: 0-0.50 mg/L). Abdominal CT with contrast showed a filling defect in the superior mesenteric and splenic vein, free perihepatic and Douglas pouch fluid, as well as small bowel thickening. An open laparotomy was performed and the necrotic segment of bowel of 80 cm was removed. The postoperative period went relatively well, despite the diarrhea that continued for the next 4 months after the intervention. The most common causes leading the development of this complication include: hypercoagulable state, dehydration, increased intra-abdominal pressure during the procedure and other secondary factors. The main symptom is abdominal pain, followed by nausea, vomiting, diarrhea and bleeding from the gastrointestinal tract. SMVT and SVT should be considered as a possible complication in patients with abdominal pain and increased inflammatory parameters after LSG. Early diagnosis through CT imaging and rapid anticoagulation therapy is considered to reduce further complications such as intestinal infarction and portal hypertension.

Insight into increased risk of portal vein thrombosis in nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is one of the leading chronic liver diseases with increased morbidity and mortality rates for extrahepatic diseases (including cardiovascular disease, portal vein thrombosis, etc.). There is an increased risk of thrombosis in both the portal and systemic circulation in patients with NAFLD, independent of traditional liver cirrhosis. However, increased portal pressure, the most critical factor, is frequently observed in NAFLD patients, predisposing them to portal vein thrombosis (PVT). It has been reported that there is an 8.5% incidence of PVT among patients with non-cirrhotic NAFLD in a prospective cohort study. Based on the prothrombotic status of NAFLD itself, patients combined with cirrhosis may accelerate the development of PVT and lead to a poor prognosis. Moreover, PVT has been shown to complicate the procedure and adversely affect the outcome during liver transplantation surgery. NAFLD is in a prothrombotic state, and its underlying mechanisms have not been fully understood so far. Particularly noteworthy is that gastroenterologists currently overlook the higher risk of PVT in NAFLD. We investigate the pathogenesis of NAFLD complicated with PVT from the perspective of primary, secondary, and tertiary hemostasis, and also summarize relevant studies in humans. Some treatment options that may affect NAFLD and its PVT are also explored to improve patient-oriented outcomes.

Hypercoagulability status, operative mortality, and long-term survival in patients operated on for mesenteric venous thrombosis

OBJECTIVE

Mesenteric venous thrombosis (MVT) is a rare cause of acute surgical abdomen, with high mortality. The aim of this study was to analyze long-term outcomes and possible factors influencing its prognosis.

METHODS

All patients who underwent urgent surgery for MVT from 1990 to 2020 in our center were reviewed. Epidemiological, clinical, and surgical data; postoperative outcomes; origin of thrombosis; and long-term survival were analyzed. Patients were divided into two groups: primary MVT (hypercoagulability disorders or idiopathic MVT) and secondary MVT (underlying disease).

RESULTS

Fifty-five patients, 36 (65.5%) men and 19 (34.5%) women, mean age 66.7 years (standard deviation: ±18.0 years), underwent surgery for MVT. Arterial hypertension (63.6%) was the most prevalent comorbidity. Regarding the possible origin of MVT, 41 (74.5%) patients had primary MVT and 14 (25.5%) patients had secondary MVT. From these, 11 (20%) patients had hypercoagulable states, 7 (12.7%) had neoplasia, 4 (7.3%) had abdominal infection, 3 (5.5%) had liver cirrhosis, 1 (1.8%) patient had recurrent pulmonary thromboembolism, and 1 (1.8%) had deep venous thrombosis. Computed tomography was diagnostic of MVT in 87.9% of the cases. Intestinal resection was performed in 45 patients due to ischemia. Only 6 patients (10.9%) had no complication, 17 patients (30.9%) presented minor complications, and 32 patients (58.2%) presented severe complications according to the Clavien-Dindo classification. Operative mortality was 23.6%. In univariate analysis, comorbidity measured by the Charlson index (P = .019) and massive ischemia (P = .002) were related to operative mortality. The probability of being alive at 1, 3, and 5 years was 66.4%, 57.9%, and 51.0%, respectively. In univariate analysis of survival, age (P < .001), comorbidity (P < .001), and type of MVT (P = .003) were associated with a good prognosis. Age (P = .002; hazard ratio: 1.05, 95% confidence interval: 1.02-1.09) and comorbidity (P = .019; hazard ratio: 1.28, 95% confidence interval: 1.04-1.57) behaved as independent prognostic factors for survival.

CONCLUSIONS

Surgical MVT continues to show high lethality. Age and comorbidity according to the Charlson index correlate well with mortality risk. Primary MVT tends to have a better prognosis than secondary MVT.

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.

Therapeutic anticoagulation for splanchnic vein thrombosis in acute pancreatitis: A national survey and case-vignette study

BACKGROUND

Splanchnic vein thrombosis (SVT) is a major complication of moderate and severe acute pancreatitis. There is no consensus on whether therapeutic anticoagulation should be started in patients with acute pancreatitis and SVT.

AIM

To gain insight into current opinions and clinical decision making of pancreatologists regarding SVT in acute pancreatitis.

METHODS

A total of 139 pancreatologists of the Dutch Pancreatitis Study Group and Dutch Pancreatic Cancer Group were approached to complete an online survey and case vignette survey. The threshold to assume group agreement was set at 75%.

RESULTS

The response rate was 67% (n = 93). Seventy-one pancreatologists (77%) regularly prescribed therapeutic anticoagulation in case of SVT, and 12 pancreatologists (13%) for narrowing of splanchnic vein lumen. The most common reason to treat SVT was to avoid complications (87%). Acute thrombosis was the most important factor to prescribe therapeutic anticoagulation (90%). Portal vein thrombosis was chosen as the most preferred location to initiate therapeutic anticoagulation (76%) and splenic vein thrombosis as the least preferred location (86%). The preferred initial agent was low molecular weight heparin (LMWH; 87%). In the case vignettes, therapeutic anticoagulation was prescribed for acute portal vein thrombosis, with or without suspected infected necrosis (82% and 90%), and thrombus progression (88%). Agreement was lacking regarding the selection and duration of long-term anticoagulation, the indication for thrombophilia testing and upper endoscopy, and about whether risk of bleeding is a major barrier for therapeutic anticoagulation.

CONCLUSION

In this national survey, the pancreatologists seemed to agree on the use of therapeutic anticoagulation, using LMWH in the acute phase, for acute portal thrombosis and in the case of thrombus progression, irrespective of the presence of infected necrosis.

High risk and low prevalence diseases: Mesenteric ischemia

INTRODUCTION

Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of mesenteric ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Mesenteric ischemia is an abdominal vascular emergency that includes superior mesenteric arterial embolism, arterial thrombosis, venous mesenteric ischemia, and non-occlusive mesenteric ischemia. It is associated with a variety of risk factors including older age, cardiovascular disease, hypercoagulable state, and end-stage renal disease. The presentation depends on the underlying pathophysiology. While arterial embolic disease may present with sudden, severe pain, the early stages of the disease and other forms can present with vague symptoms, including generalized abdominal pain, weight loss, vomiting, and diarrhea. Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis. The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases. The initial ED management includes fluid resuscitation, symptomatic therapy, broad-spectrum antibiotics, and anticoagulation. Emergent consultation with a multidisciplinary team including diagnostic and interventional radiologists and cardiovascular and general surgeons is necessary for definitive treatment.

CONCLUSIONS

An understanding of mesenteric ischemia can assist emergency clinicians in diagnosing and managing this disease.

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%.

Efficacy of endovascular treatment for completely occlusive acute-subacute portal and mesenteric vein thrombosis with severe complications in patients without cirrhosis

PURPOSE

Completely occlusive acute-subacute portal and mesenteric vein thrombosis (PVMVT) with severe complications is fatal. Endovascular treatments (EVTs) of acute-subacute PVMVT are not standardized. Thrombectomy combined with continuous catheter-directed thrombolysis is considered an effective treatment. Here, we aimed to evaluate the outcome of EVTs of completely occlusive acute-subacute PVMVT with severe complications in patients without cirrhosis.

MATERIALS AND METHODS

Nineteen patients (nine men and 10 women; age, 60.1 ± 16.8 years) with completely occlusive acute-subacute PVMVT were retrospectively assessed. Acute-subacute PVMVT was defined as symptom onset within 40 days, with no cavernous transformation observed on contrast-enhanced computed tomography. The patients were treated with EVTs, a combination of thrombectomy (including aspiration thrombectomy, plain old balloon angioplasty, single injection of thrombolytic agents, and stent placement) and continuous catheter-directed thrombolysis. Kaplan-Meier analyses were performed to assess all-cause mortality, acute-subacute PVMVT-related mortality, and portal vein (PV) patency. The degree of recanalization and patency of PV, complications, factors related to acute-subacute PVMVT-related mortality, and factors related to patency of PV were also evaluated.

RESULTS

The all-cause and acute-subacute PVMVT-related mortality rates were 36.8% (7/19) and 31.6% (6/19), respectively. Seven (36.8%) and 11 (57.9%) patients achieved complete and partial recanalization, respectively. Among the 18 patients who achieved recanalization, follow-up images after 608.7 ± 889.5 days confirmed recanalization in 83.3% (15/18) patients, and 53.3% (8/15) of these patients achieved patency of PV. Seven patients (36.8%) developed complications, and two (10.5%) required interventional treatment for complications. Deterioration of liver function significantly worsened the prognosis (P = 0.046), while anticoagulation therapy significantly maintained portal patency (P = 0.03).

CONCLUSION

This endovascular method for acute-subacute PVMVT, which combines thrombectomy and continuous catheter-directed thrombolysis EVT approach was effective for thrombus resolution. However, further studies must define conditions that improve patient prognosis.

A clinical analysis of intestinal mucosal necrosis and exfoliation induced by superior mesenteric vein thrombosis: A case report

Background

Superior mesenteric vein (SMV) thrombosis is a rare intestinal ischemic disease. The clinical manifestations of patients differ, and most experience gastrointestinal symptoms.

Case summary

A 45-year-old female patient presented with persistent abdominal pain and abnormal vaginal bleeding for 7 days. A physical examination revealed significant abdominal tenderness with positive rebound tenderness. A laboratory examination revealed a white blood cell count of 27 × 10⁹/l, hemoglobin level of 52 g/L, and D-dimer of 4.54 mg/l. Enhanced computed tomography revealed a thickening and swelling of the jejunum and ileum in the left upper quadrant and portal vein. Filling defects in the main lumen and branch lumen suggested the possibility of portal vein and superior mesenteric vein thrombosis. Symptoms improved after treatment with low-molecular-weight heparin and warfarin. One month later, the patient developed occasional dull pain in the left lower quadrant, with long strips of discharge. An electronic colonoscopy revealed avascular necrosis and tissue exfoliation of the intestinal mucosa. After the continuation of warfarin therapy, the abdominal pain resolved. Five months later, the patient experienced recurrent abdominal pain and vomiting. A physical examination revealed a blood pressure of 75/49 mm Hg. An incomplete ileus with the portal and superior mesenteric vein thrombosis was diagnosed, partial jejunectomy and gastrointestinal bypass anastomosis were performed, and warfarin was continued postoperatively.

Conclusion

The intestinal mucosal shedding observed, in this case, was caused by SMV thrombosis, which enriched the clinical manifestations of the disease and provided a new basis for the clinical diagnosis of SMV thrombosis.

Superior mesenteric vein thrombosis and osteoporotic vertebral fractures

Superior mesenteric vein (SMV) thrombosis is relatively rare disease with unspecific symptoms. Thrombus formation within the SMV eventually leads to congestive intestinal necrosis. In most cases, the lack of specific symptoms makes early diagnosis difficult. Therefore, it is important to suspect the disease and actively investigate it, given a causative factor. Here, we report a case of SMV thrombosis with a novel predisposing factor, compression of SMV by deformed spine, found on contrast medium-enhanced computed tomography. Treatment with intravenous heparin followed by oral anticoagulants resulted in favorable outcome. This is the first picture showing the novel mechanism of SMV thrombus formation relating to spinal deformity. Treating osteoporosis before spinal deformity could prevent SMV thrombosis with such a mechanism.

Acute mesenteric thrombosis in a pregnant woman with Factor V Leiden mutation with a history of in vitro fertilization and embryo transfer: case report and literature review

Objectives

To report the case of a patient diagnosed with acute mesenteric vein thrombosis (AMVT) associated with Factor V Leiden mutation and a history of in vitro fertilization and embryo transfer and review the literature on risk factors and treatments performed for AMVT.

Materials and methods

We reported the case of a 37-year-old pregnant woman. A bibliographic search was carried out in Medline/PubMed and LILACS, filtering by type of language (English and Spanish). Primary cohort studies, cases and controls, case reports and case series were included, which addressed the risk factors associated with the development of acute mesenteric thrombosis during pregnancy and treatments performed.

Results

The search identified cases and control studies, case reports and case series related to mesenteric ischemia, pregnancy and in vitro fertilization. The literature reported that the main factors associated with mesenteric ischemia are pregnancy itself, genetic factors, drugs, protein C and protein S deficiency and idiopathic causes.

Conclusions

SMV thrombosis is a life-threatening and very rarely seen condition that emerges in pregnancies. The literature suggests that, during gestation, the factors associated with the development of acute mesenteric thrombosis are hypercoagulability induced by pregnancy, the administration of oral estrogen during IVF-ET, and other precipitating factors. More studies are required to better understand the possible additional factors and build better optimal treatment algorithms.

The Role of Thromboprophylaxis in Patients with Portal Vein Thrombosis: A Life-Threatening Complication after Laparoscopic Sleeve Gastrectomy Following 8 Years of Experience in a Bariatric Center of Excellence

Porto-mesenteric vein thrombosis (PVMT) is a rare but life-threatening complication after laparoscopic sleeve gastrectomy (LSG). Laparoscopic sleeve gastrectomy (LSG) is considered the most common procedure for efficiently realizing weight loss and treating obesity-related co-morbidities. This study aimed to shed light on this relatively rare complication by presenting a series of patients who developed PMVT after LSG in light of the need to change the specific protocol of thromboprophylaxis in bariatric patients. We proposed to answer two questions: whether we should perform a thrombophilia workup as a standard practice and whether we should extend chemoprophylaxis to more than 3 weeks among all bariatric patients. This study also aimed to investigate the possible risk factors and eventually present our updated protocol for PMVT management and prophylaxis.

Successful heparin-perfusion therapy for complete thrombosis of the intra- and extrahepatic portal and mesenteric vein. A case report and literature review

The initial treatment of acute and subacute portal vein thrombosis, which is the most common cause of portal vein occlusion, consists of intravenous anticoagulation with heparin, but there is still a huge uncertainty among physicians regarding the role of more invasive therapies. We report a 61-year-old male patient, who presented in our emergency room with a subacute complete thrombosis of the intra- and extrahepatic portal vein, mesenteric vein, with associated venous congestion of 20-30 cm length of the small intestine with a quick and complete remission of the portal vein thrombosis under sole i.v. heparin-perfusor therapy without any complications. Molecular genetic analysis found combined genetic mutations of the gene factor 2 (c.20210G>A, heterozygotic), SERPINE1 (-675 5G>4G, heterozygotic), and the MTHFR gene. Along with this interesting case, we also present the recent status of portal vein thrombosis and portal vein occlusion in the literature.

A Rare Case of Portal Vein Thrombosis Following a Successful Laparoscopic Cholecystectomy

The function of the portal vein is to drain the blood mainly from the gastrointestinal tract to the liver and its thrombosis is an extremely unexpected outcome of an uncomplicated laparoscopic cholecystectomy. It is believed to be a rarely reported case to date in non-cirrhotic patients. A female patient, aged 43 years, presented to the surgical outpatient department with unexplained severe abdominal pain soon after laparoscopic cholecystectomy. A relative workup was done and radiological evidence revealed the thrombosis in the distal part of the portal vein at its bifurcation which completely occluded the left branch of the vein. Although rare, portal vein thrombosis should be concluded in the differentials for unexplained causes of abdominal pain in the postoperative period of laparoscopic cholecystectomy.

Successful treatment of acute symptomatic extensive portal venous system thrombosis by 7-day systemic thrombolysis

Acute portal venous system thrombosis (PVST) can cause acute mesenteric ischemia and even intestinal infarction, which are potentially fatal, and requires recanalization in a timely fashion. Herein, we report a 56-year-old man with acute non-cirrhotic symptomatic extensive PVST who achieved portal vein recanalization after systemic thrombolysis combined with anticoagulation. Initially, anticoagulation with enoxaparin sodium for 4 d was ineffective, and then systemic thrombolysis for 7 d was added. After that, his abdominal pain completely disappeared, and portal vein system vessels became gradually patent. Long-term anticoagulation therapy was maintained. In conclusion, 7-d systemic thrombolysis may be an effective and safe choice of treatment for acute symptomatic extensive PVST which does not respond to anticoagulation therapy.

Splenic vein thrombosis in cirrhosis of the liver: A rare case

Splenic Vein Thrombosis (SpVT) in a young patient with non-hepatitis B and C liver cirrhosis is an infrequent case generating hemorrhagic manifestations. Herein we report a 28-year-old man presenting with hematemesis, melena, and features of liver cirrhosis. Hematemesis, melena, and ascites resolve following a conservative treatment. Abdominal ultrasound confirmed portal hypertension. Serial endoscopy on day 14, 17 and 1-month evaluation showed grade II-III esophageal varices and severe hypertensive portal gastropathy. Abdominal CT scan with contrast within 1 week after discharge revealed thrombus along ± 5.8 cm, splenomegaly with dilated splenic vein, dilatation and tourtosity of the left gastric vein and visualized distal esophageal vein. Liver biopsy 2 months after hospitalization showed hepatocytes with extensive hydropic degeneration with fibrosis (F3).

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Splenic Vein Thrombosis (SpVT) occurring in a young patient is a rare case

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SpVT might occur without relating to hepatitis-B or hepatitis-C infection.

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In this situation, even mostly asymptomatic, gastrointestinal bleeding secondary to esophageal or gastric varices commonly arises.

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Heparinization should be done to increase survival and prevent recurrent thrombosis.

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Immediate splenectomy is strongly recommended in patients with bleeding esophageal varices to prevent massive bleeding.

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.

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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.

Primary Catheter-Directed Thrombolysis for Porto-Mesenteric Venous Thrombosis (PMVT) in Non-Cirrhotic Patients

Purpose: To report our thrombolytic technique, treatment strategy, and clinical outcomes for porto-mesenteric venous thrombosis (PMVT) in non-cirrhotic patients. Methods: Sixteen acute or chronic non-cirrhotic PMVT patients (mean age: 48.6 years) with imminent intestinal ischemia were enrolled from 2004 to 2020. Eight patients presented thrombus extension into the peripheral mesenteric vein, close to the venous arcade. Transhepatic catheter-directed thrombolysis (CDT) was performed by urokinase infusion (60,000–30,000 IU/h concomitant with heparin 300–400 IU/h), catheter aspiration, and/or balloon dilation/stent placement. Additional intra-arterial mesenteric infusion of urokinase (30,000 IU/h) was given in patients with the peripheral mesenteric venules involved. Transjugular intrahepatic porto-systemic shunt (TIPS) was created in patients with poor recanalization of the intrahepatic portal flow (PV). Results: The transhepatic route was adopted in all patients, with adjunct indirect mesenteric arterial thrombolytic infusion in eight patients. A total of up to 20.4 million IU urokinase was infused for 1–21 days’ treatment duration. TIPS was created in three patients with recanalization failure of the intrahepatic PV. Technical success was achieved in 100% of patients with complete recanalization of 80% and partial recanalization of 20%. No major procedure-related complications were encountered. The 30-day mortality rate was 6.7%. The overall two-year primary patency was 84.6%. Conclusions: CDT can be performed as a primary salvage treatment once the diagnosis is made. CDT via the transhepatic route with tailored thrombolytic regimen is safe and effective for both acute and chronic PMVT. TIPS creation can be preserved in non-cirrhotic PMVT patients if intrahepatic PV recanalization fails.

Comprehensive review of acute small bowel ischemia: CT imaging findings, pearls, and pitfalls

Acute small bowel ischemia is a life-threatening condition with a high mortality rate due to its lack of specific symptoms and laboratory profile, which render difficulty in establishing early diagnosis. The etiology of acute small bowel ischemia includes occlusive forms (arterial embolism, arterial thrombosis, and venous thrombosis) and nonocclusive mesenteric ischemia, of which arterial causes are far more common than venous causes. CT, the mainstay of accurate diagnoses, allows the identification of the features of vascular abnormalities and intestinal ischemic injuries, and helps clinicians to restore intestinal blood flow. Without treatment, the prognosis for acute small bowel ischemia is poor. A high index of suspicion and familiarity with the CT spectral findings of bowel ischemia are required to ensure rapid recognition of this condition.

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.

Clinical significance of hepatosplenic thrombosis in vaccine-induced immune thrombotic thrombocytopenia after ChAdOx1 nCoV-19 vaccination

BACKGROUND

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare, serious complication after adenoviral COVID-19 vaccine administration that can involve various organ systems. We aimed to investigate the clinical significance of hepatosplenic thrombosis in patients with VITT.

METHODS

We searched PubMed ePubs, Scopus, Embase, and Web of Science databases for studies published until April 28, 2021 involving patients with VITT after ChAdOx1 nCoV-19 vaccination. Demographic and clinical characteristics including laboratory measurements were collected and compared.

RESULTS

Four case series and three case reports involving 48 cases of VITT were included. Hepatosplenic thrombosis was present in eight cases (17%). Patients with hepatosplenic thrombosis had lower platelet counts (13,000 vs. 29,500/μL, p=0.016) and higher D-dimer levels (140.0 vs. 57.3 times upper limit of normal range, p=0.028). Multiple-site thrombosis was also associated with hepatosplenic thrombosis (88% vs. 15%, p<0.001).

CONCLUSIONS

This is the first study comparing clinical profiles of patients with VITT according to the presence of hepatosplenic thrombosis. Patients with hepatosplenic thrombosis had more severe presentations with lower platelet counts, higher D-dimer levels, and higher rate of multiple-site thromboses. Further studies with larger sample sizes are required to establish definitive evidence regarding the significance of hepatosplenic thrombosis in VITT.

Validation of color Doppler ultrasound and computed tomography in the radiologic assessment of non-malignant acute splanchnic vein thrombosis

INTRODUCTION

International guidelines propose color Doppler ultrasound (CDUS) and contrast-enhanced computed tomography (CT) as primary imaging techniques in the diagnosis of acute splanchnic vein thrombosis. However, their reliability in this context is poorly investigated. Therefore, the aim of our study was to validate CDUS and CT in the radiologic assessment of acute splanchnic vein thrombosis, using direct transjugular spleno-portography as gold standard.

MATERIALS AND METHODS

49 patients with non-malignant acute splanchnic vein thrombosis were included in a retrospective, multicenter analysis. The thrombosis' extent in five regions of the splanchnic venous system (right and left intrahepatic portal vein, main trunk of the portal vein, splenic vein, superior mesenteric vein) and the degree of thrombosis (patent, partial thrombosis, complete thrombosis) were assessed by portography, CDUS and CT in a blinded manner. Reliability of CDUS and CT with regard to portography as gold standard was analyzed by calculating Cohen's kappa.

RESULTS

Results of CDUS and CT were consistent with portography in 76.6% and 78.4% of examinations, respectively. Cohen's kappa demonstrated that CDUS and CT delivered almost equally reliable results with regard to the portographic gold standard (k = 0.634 [p < 0.001] vs. k = 0.644 [p < 0.001]). In case of findings non-consistent with portography there was no clear trend to over- or underestimation of the degree of thrombosis in both CDUS (60.0% vs. 40.0%) and CT (59.5% vs. 40.5%).

CONCLUSIONS

CDUS and CT are equally reliable tools in the radiologic assessment of non-malignant acute splanchnic vein thrombosis.

A Case of Idiopathic Portal Vein Thrombosis in an Immunocompetent Female

Portal vein thrombosis (PVT) is characterized by a complete or partial occlusion of the portal vein by a thrombus. The formation of the thrombus is usually attributed to an underlying condition that is causing a hypercoagulable state, such as malignancy or cirrhosis. When these causes are ruled out, a hypercoagulable workup can reveal other underlying prothrombotic etiologies. Still, some cases of PVT occur without any definitive underlying condition, leading to the diagnosis of idiopathic PVT. This occurred in our patient, a 53-year-old female who presented with PVT but had no clear underlying condition that led to her pathology after an extensive medical investigation.

Isolated Multifocal Superior Mesenteric Artery Vasculitis With Coexisting Superior Mesenteric Vein Thrombosis: A Unique Coincidence

Vasculitis involving the gastrointestinal (GI) tract typically occurs in association with multisystem disease. Isolated superior mesenteric artery (SMA) vasculitis is a rare disorder that has a high degree of morbidity and mortality. Patients often present with nonspecific symptoms, and this condition can lead to varying degrees of intestinal ischemia, significant gastrointestinal bleeding, and bowel infarction, leading to perforation, peritonitis, and sepsis from bacterial translocation. Diagnosing this condition can be very challenging. High clinical suspicion and early diagnosis using both laboratory workup and appropriate vascular imaging are pivotal in improving outcomes in such patients. Herein, we describe the case of isolated yet multifocal SMA vasculitis with coexisting superior mesenteric vein (SMV) thrombosis. Medical therapy alone resulted in clinical and radiographic improvements. To our knowledge, there have not been any previous reports of this unique coexistence.

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.

[Acute venous mesenteric ischemia in a young COVID-19 positive subject: a case report]

L'ischémie mésentérique aiguë (IMA) résulte d'une diminution ou d'une interruption brutale du flux sanguin mésentérique ayant pour conséquence un apport sanguin inadéquat au tractus gastro-intestinal, responsable de lésions ischémiques et inflammatoires évoluant souvent vers une nécrose en l'absence de traitement adapté, l´insuffisance vasculaire peut résulter d'une embolie ou d'une thrombose artérielle ou d'une thrombose veineuse. Nous présentons un cas rare d´ischémie veineuse mésentérique chez un homme de 33 ans dû au coronavirus (COVID-19) chez qui le diagnostic était fait grâce à l´échographie et surtout à la tomodensitométrie (TDM).

Evolution of Nonmalignant Portal Vein Thrombosis in Liver Cirrhosis: A Pictorial Review

Portal vein thrombosis (PVT) is a common complication in liver cirrhosis, especially in advanced cirrhosis. It may be related to a higher risk of liver-related events and liver function deterioration. Imaging examinations can not only provide an accurate diagnosis of PVT, such as the extent of thrombus involvement and the degree of lumen occupied, but also identify the nature of thrombus (i.e., benign/malignant and acute/chronic). Evolution of PVT, mainly including development, recanalization, progression, stability, and recurrence, could also be assessed based on the imaging examinations. This article briefly reviews the pathophysiology, diagnosis, classification, and evolution of PVT with an emphasis on their computed tomography imaging features.

CT manifestations of small bowel ischemia due to impaired venous drainage-with a correlation of pathologic findings

Acute abdominal pain may result from a wide variety of medical and surgical diseases. One of these diseases is small bowel ischemia, which may result in a catastrophic outcome if not recognized and treated promptly. Computed tomography (CT) by its faster image acquisition, thinner collimation, high resolution, and multiplanar reformatted images has become the most important imaging modality in evaluating the acute abdominal conditions. In this article, the author presents a description of the histology of the small bowel, pathophysiology of small bowel change, and a correlation of the pathologic and CT findings of the small bowel injuries due to impaired venous drainage. A convincing correlation of the microscopic mucosal condition with the enhancement pattern of the thickened small bowel wall on CT is useful in definitely describing the mucosal viability.

Acute Mesenteric Vein Thrombosis in a Pregnant Patient at 10 Weeks Gestation: A Case Report

Acute abdominal pain during pregnancy is challenging, both from a diagnostic and management perspective. A non-localized, persistent pain out of proportion to physical examination is a sign that advanced imaging may be necessary. Mesenteric venous thrombosis in a pregnant patient is extremely rare, but if diagnosis is delayed, can be potentially fatal to both the mother and the fetus. We present here a pregnant patient in the tenth week of gestation with classic clinical manifestations of mesenteric vein thrombosis and the corresponding findings on magnetic resonance imaging (MRI) and computed tomography (CT).

Clinical Predictors of Morbidity and Mortality in Hospitalized Pediatric Patients With Ascites

OBJECTIVES

Ascites is a pathologic buildup of fluid in the peritoneal cavity. Knowledge is lacking in clinical outcome in pediatric patients with ascites. We aim to identify and assess clinical variables, associated with morbidity and mortality in pediatric patients who are hospitalized with ascites.

METHODS

A retrospective cohort study was performed on patients ages 0 to 21 hospitalized at Johns Hopkins Hospital between 1983 and 2010 with an ICD-9 discharge diagnosis of ascites (789.5, 789.51, 789.59). A total of 518 pediatric patients were studied, all with a diagnosis of ascites during hospitalization. Study outcomes included hospital length of stay (LOS) as a proxy for morbidity and death at hospital discharge for mortality. Variables analyzed included demographic data, ascites etiology and grade, comorbidities, and laboratory markers. Variables were analyzed by log-linear regression and competing risk model.

RESULTS

Among the 3 age groups (0-5, 6-12, and 13-21), the 0 to 5 age group experienced significantly increased LOS (P < 0.001) and mortality (P = 0.027). Ascites etiology of veno-occlusive disease (VOD) and the presence of hydrothorax or thrombocytopenia was also significantly associated with increased LOS. Ascites with the etiology of congestive hepatopathy and the presence of grade 3 ascites, hepatic encephalopathy, hepatorenal syndrome, hydrothorax, hyponatremia, and thrombocytopenia were associated with increased mortality. Additionally, black pediatric patients have an increased risk of mortality (P = 0.027). Other factors including sex, leukopenia, portal vein thrombosis, and splenomegaly were not associated with LOS or mortality.

CONCLUSIONS

Morbidity and mortality in pediatric patients hospitalized with ascites are associated with specific demographic and clinical factors. Further studies are required to apply this knowledge to predict the clinical outcomes.

Dual Pathology: A Rare Association in Surgical Acute Abdomen

Among the causes of acute surgical abdomen intestinal perforation and mesenteric ischemia are some of the leading causes of morbidity and mortality. Gastric perforation has a mortality rate of 20-30% and mesenteric ischemia has a mortality of 60%. The presence of both pathologies in the same patient at the same time is a rare association and very few cases have been reported till now. This association has been described in cases of polyarteritis nodosa. Here we are presenting our case in which no such vascular pathology was identified. We have tried to hypothesize the reason behind this rare association.

Right paraduodenal hernia accompanying superior mesenteric vein thrombosis: a rare case

A 59-year-old man with abdominal pain was admitted to the emergency department. Investigations had revealed a right-sided paraduodenal hernia and superior mesenteric vein (SMV) twisting around the superior mesenteric artery in rotation, the 'whirlpool sign'. Owing to the increasing severity of abdominal pain and the presence of SMV thrombosis complicated with strangulated paraduodenal herniation associated with high mortality rates, diagnostic laparoscopy was performed. Resection of the intestines was not needed and paraduodenal hernia was repaired. The patient was uneventfully discharged.

Homozygous Factor V Leiden presenting as irreversible chronic colon ischemia resulting from inferior mesenteric vein thrombosis

A 42-year-old man presented with 6 months of unexplained left lower quadrant abdominal pain and hematochezia accompanied by weight loss despite extensive evaluations. Stool studies for pathogens were unrevealing, but an abdominal contrast-enhanced computed tomography revealed findings of chronic inferior mesenteric vein thrombosis. Colonoscopy demonstrated ulcerated strictures and gangrene confined to the sigmoid and descending colons, and biopsies confirmed changes of chronic irreversible colon ischemia. A homozygous Factor V Leiden mutation was diagnosed. The patient underwent colectomy and was treated with lifelong anticoagulation. While mesenteric venous thrombosis is a well-recognized cause of colon ischemia in hypercoagulable states, thrombosis of the inferior mesenteric vein is uncommon; when chronic it is rarely clinically apparent. Similarly, while Factor V Leiden mutation is a common hereditary thrombophilia, it uncommonly causes mesenteric venous thrombosis, and homozygotes of the mutation typically present earlier in the fourth decade and with non-mesenteric venous thromboembolism. This case is valuable and adds to the existing literature in describing a rare, clinically atypical, and late index presentation of homozygous Factor V Leiden mutation as chronic inferior mesenteric vein thrombosis yielding irreversible colon ischemia.

A systematic review and meta-analysis on endovascular treatment as an attractive alternative for acute superior mesenteric venous thrombosis

OBJECTIVE

This systematic review and meta-analysis evaluated the published data on the efficacy and safety of therapies for superior mesenteric venous thrombosis (SMVT), aiming to provide a reference and set of recommendations for clinical treatment.

METHODS

Relevant databases were searched for studies published from 2000 to June 2020 on SMVT treated with conservative treatment, surgical treatment, or endovascular approach. Different treatment types were grouped for analysis and comparison, and odds ratios with corresponding 95% confidence intervals were calculated. The outcomes were pooled using meta-analytic methods and presented by forest plots.

RESULTS

Eighteen articles, including eight on SMVT patients treated with endovascular therapies, were enrolled. The treatment effectiveness was compared between different groups according to the change of symptoms, the occurrence of complications, and mortality as well. The conservative treatment group had better efficacy compared to the surgery group (89.0% vs. 78.6%, P <0.05), and the one-year survival rate was also higher (94.4% vs. 80.0%, P >0.05), but without statistical significance. As for endovascular treatment, the effectiveness was significantly higher than the surgery group (94.8% vs. 75.2%, P <0.05), and the conservative treatment group as well (93.3% vs. 86.3%, P >0.05), which still requires further research for the lack of statistical significance.

CONCLUSIONS

Present findings indicate that anticoagulation, as conservative treatment should be the preferred clinical option in the clinic for SMVT, due to its better curative effect compared to other treatment options, including lower mortality, fewer complications, and better prognosis. Moreover, endovascular treatment is a feasible and promising approach that is worth in-depth research, for it is less invasive than surgery and has relatively better effectiveness, thus can provide an alternative option for SMVT treatment and may be considered as a reliable method in clinical.

Many faces of acute bowel ischemia: overview of radiologic staging

Acute bowel ischemia (ABI) can be life threatening with high mortality rate. In spite of the advances made in diagnosis and treatment of ABI, no significant change has occurred in the mortality over the past decade. ABI is potentially reversible with prompt diagnosis. The radiologist plays a central role in the initial diagnosis and preventing progression to irreversible intestinal ischemic injury or bowel necrosis. The most single imaging findings described in the literature are either non-specific or only present in the late stages of ABI, urging the use of a constellation of features to reach a more confident diagnosis. While ABI has been traditionally categorized based on the etiology with a wide spectrum of imaging findings overlapped with each other, the final decision for patient’s management is usually made on the stage of the ABI with respect to the underlying pathophysiology. In this review, we first discuss the pathologic stages of ischemia and then summarize the various imaging signs and causes of ABI. We also emphasize on the correlation of imaging findings and pathological staging of the disease. Finally, a management approach is proposed using combined clinical and radiological findings to determine whether the patient may benefit from surgery or not.

SARS-CoV-2 and Portal Vein Thrombosis: A Rare Gastrointestinal Manifestation of COVID-19

Portal vein thrombosis is defined as a clot within the trunk or intrahepatic branches of the portal vein. Sequelae involves either partial or complete recanalization. However, in patients with liver disease, it can progress to a cavernoma instead of recanalization. This can result in gastrointestinal bleeding and intestinal infarction. Its rising incidence in severe acute respiratory syndrome coronavirus 2 is an important clinical aspect that needs to be addressed and treated.

Acute mesenteric ischaemia due to superior mesenteric vein (SMV) thrombosis

A 77-year-old male patient presented with a 5-day history of abdominal pain, coffee ground vomiting and blood-stained diarrhoea. CT scan of the abdomen and pelvis demonstrated a long segment thrombotic occlusion of the superior mesenteric vein (SMV) extending up to the proximal portion of the portal vein causing significant acute small bowel ischaemia. Patient's deteriorating clinical condition warranted surgical management. Successful surgical management required multidisciplinary teamwork between emergency, vascular surgeons, anaesthetists and intensivists. Emergency laparotomy revealed gangrene of an estimated 120 cm of small bowel segment starting from duodenojejunal junction and a long segment thrombotic occlusion of the SMV extending up to the portal confluence. Resection of gangrenous small bowel without anastomosis and thrombo-embolectomy of SMV along with laparostomy was done at the initial operation. Patient was admitted in the intensive care unit on systemic heparinisation through intravenous administration of unfractionated heparin. Second relook exploration was done after 48 hours followed by anastomosis of the small bowel and closure of the abdomen. Patient made a good recovery following anticoagulation therapy and was discharged on postoperative day 10.

Venous mesenteric ischemia carries high procedural burden and elevated mortality in patients with severe presentation

OBJECTIVE

Venous mesenteric ischemia (VMI) presents with variable severity resulting in a spectrum of outcomes. This study sought to characterize the natural history of VMI and identify drivers of intervention and adverse outcomes.

METHODS

All patients who presented to our institution with acute and subacute VMI between 1993 and 2016 were identified. Images were reviewed to determine thrombosis location and charts were reviewed to identify clinical factors and outcomes. Univariate analysis was performed for demographics, comorbidities, and presenting characteristics, with primary outcomes of intervention, readmission, and 30-day mortality. A survival analysis was performed with log-rank difference testing for demographics, comorbidities, and presenting characteristics.

RESULTS

We identified 103 patients with acute and subacute VMI. The locations of the thrombosis included the superior mesenteric vein (SMV) (31.1%); SMV and portal vein (35.9%); SMV, portal, and splenic veins (15.5%); and other combinations of portomesenteric veins (17.4%), without correlation between the location and outcomes. Most patients were male (60.6%), 22.3% were actively smoking, and the median Charlson comorbidity score was 4 (interquartile range, 2-7). The mean patient age was 61.3 years. More than one-half had a known hypercoagulability (52.4%), 22.3% had prior bowel resection, and 8.7% had prior mesenteric venous intervention, including transjugular intrahepatic portosystemic shunt procedures. Thirty-five patients underwent 83 procedures during their hospitalization, and 23 patients underwent surgical intervention specifically. Prior mesenteric venous procedure, abdominal tenderness, and lactatemia of more than 1.5 mmol/L were associated with an increased need for surgical intervention (P < .05). Patients with leukocytosis of greater than 10K/μL had increased surgical intervention (P = .10), although without statistical significance. However, symptoms for less than 2 weeks (P < .05) were associated with decreased surgical intervention. The 30-day mortality was low in this cohort (6.8%), but was increased in patients requiring intervention (11.4%). For those undergoing procedures, a shorter time to intervention was associated with an improved 30-day mortality (8.7% for procedures on hospital days 0-1 vs 16.7% for hospital day 2 or later; P = .01). Abdominal tenderness and lactatemia were associated with increased 30-day mortality (6.8% vs 3.6% [P < .01] and 16.0% vs 3.8% [P = .03], respectively). A Kaplan-Meier survival analysis revealed a median survival of 7.1 years, with a 1-year survival rate of 74.9%, a 3-year survival rate of 67.1%, and a 5-year survival rate of 57.9%. Negative predictors of survival included a higher Charlson comorbidity index (hazard ratio, 3.7; P < .01) and malignancy (hazard ratio, 3.1; P < .01).

CONCLUSIONS

The 30-day mortality of VMT is low, but more than one-third of patients required an intervention beyond anticoagulation. Comorbidity, a prior mesenteric vessel or intestinal operation, and presentation with tenderness or relevant laboratory abnormalities portend worse outcomes. Early intervention is associated with improved outcomes.

Incidence and predictors of splanchnic vein thrombosis and mortality following hepatobiliary and pancreatic surgery

BACKGROUND

Intraabdominal surgery is a known risk factor for splanchnic vein thrombosis (SVT). SVT incidence, management, and prognosis after hepatopancreatobiliary surgery are unknown.

OBJECTIVES

To determine the incidence and prognosis of SVT following hepatopancreatobiliary surgery and describe current practices in anticoagulation for postoperative SVT.

PATIENTS/METHODS

Multicenter retrospective cohort study of adults undergoing hepatopancreatobiliary surgery. Multivariable analyses for predictors of SVT, major bleeding, and 90-day mortality were performed.

RESULTS

Of 1815 patients included, 89 (4.9%) had cirrhosis and 1532 (84.4%) had active cancer. The most frequent surgeries were pancreaticoduodenectomy (40.6%), open (30.7%), and laparoscopic (11.0%) liver resection. Sixty (3.3%) patients experienced SVT within 90 days of surgery. Among patients with SVT, 23.3% were symptomatic and 75.0% were treated with therapeutic anticoagulation. Planned duration of anticoagulation averaged 3 to 6 months. By multivariable analysis, SVT predictors were: operative time (adjusted odds ratio [aOR] per hour increase 1.32, 95% confidence interval [CI] 1.20-1.46), cirrhosis (aOR 3.22, 95% CI 1.28-8.10), and postoperative intraabdominal infection (aOR 2.99, 95% CI 1.72-5.19). Postoperative major bleeding occurred in 22.1% of patients and 4.0% died within 90 days. Predictors of postoperative mortality were age (aOR per 10-year increase 1.79, 95% CI 1.38-2.30), operative time (aOR 1.31 (1.17-1.45), cirrhosis (aOR 4.42, 95% CI 1.96-9.96), postoperative intraabdominal infection (aOR 2.66, 95% CI 1.55-4.57), postoperative major bleeding (aOR 4.12, 95% CI 2.36-7.30), and postoperative SVT (aOR 3.15, 95% CI 1.42-6.97).

CONCLUSION

SVT occurred in 1 in 30 patients after hepatopancreatobiliary surgery and was associated with a 3-fold independent increase in 90-day mortality.

Predictors and risk factors for intestinal necrosis in patients with mesenteric ischemia

Background

Mesenteric ischemia results in blood flow that is insufficient to meet metabolic demands and subsequent dysfunction of visceral organs, including arterial obstruction and venous thrombosis. Sustained mesenteric ischemia exhausts the ability of capillaries to provide oxygen and initiate an inflammatory reaction, and eventually leads to intestinal mucosal necrosis, a serious and potentially life-threatening condition. Therefore, it is essential that the predictors and risk factors for intestinal necrosis in patients with mesenteric thrombus are explored.

Methods

This study retrospectively enrolled 41 patients with mesenteric ischemia (including mesenteric vein embolism, mesenteric artery thrombosis, and portal vein thrombosis) who were admitted to the Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital between May 2016 and October 2019; of the patients, 18 were further diagnosed with intestinal necrosis. Comparisons of symptoms, computed tomography angiography (CTA) features, and laboratory examination results were performed between mesenteric ischemia patients with and without intestinal necrosis.

Results

White blood cell count showed an excellent predictive ability for intestinal necrosis in patients with mesenteric ischemia, with an area under the receiver operating characteristic (ROC) curve of 0.772 (P=0.009). The four CTA features [pneumatosis (P=0.016), intestinal swelling (P=0.006), ascitic fluid (P<0.001), and decreased intestinal wall enhancement (P=0.004)] differed significantly between patients with and without intestinal necrosis. Peritonitis showed a strong association with intestinal necrosis (P=0.006) in the univariate analysis, and multivariate analysis further showed their association [odds ratio (OR): 8.53; 95%CI: 1.46-49.81; P=0.017].

Conclusions

White blood cell count is a potential predictor of intestinal necrosis. Peritonitis is a possible risk factor for intestinal necrosis in patients with mesenteric ischemia. A multi-center prospective study with a larger sample size needs to be performed to further investigate these findings.

Use of dipeptidyl peptidase-4 inhibitors and risk of splanchnic vein thrombosis: A Danish nationwide new-user active comparator cohort study

Use of dipeptidyl peptidase-4 (DPP-4) inhibitors, on the basis of spontaneous adverse event reports, has recently been suspected of causing splanchnic vein thrombosis. Here, we report the results of a population-based new-user active comparator cohort study addressing this hypothesis, comparing DPP-4 inhibitor initiators (n = 75 042) with initiators of glucagon-like-peptide-1 receptor agonists (GLP-1RAs) or sodium-glucose co-transporter-2 (SGLT2) inhibitors (n = 38 718). We estimated the hazard ratio (HR) associating DPP-4 inhibitor use with risk of splanchnic vein thrombosis using Cox regression. In a crude analysis, the incidence rate of splanchnic vein thrombosis was 0.22/1000 person-years among DPP-4 inhibitor initiators, compared to 0.17 among GLP-1RA/SGLT2 inhibitor initiators, corresponding to an unadjusted absolute incidence rate difference of 0.05 (95% confidence interval [CI] -0.04 to 0.14) and an HR of 1.29 (95% CI 0.78 to 2.15). Adjusting for potential confounders using stabilized inverse probability of treatment weighing, we obtained an absolute incidence rate difference of 0.03/1000 person-years (95% CI -0.07 to 0.14) and an HR of 1.18 (95% CI 0.62 to 2.26). No evidence of increased risk of splanchnic vein thrombosis was found in supplementary analyses, including an absence of any dose-response patterns. As such, we found no association between DPP-4 inhibitor use and splanchnic vein thrombosis risk.

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.