Mesenteric venous thrombosis: a diagnosis not to be missed!

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.

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.

Paroxysmal nocturnal hemoglobinuria: When delay in diagnosis and long therapy occurs

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare clonal disorder characterized by hemolytic anemia, bone marrow failure and thrombosis, caused by a somatic mutation in PIG-A gene that results in the absence of CD55 and CD59, two important complement regulatory proteins. In this paper, a case of PNH is retrospectively examined looking for clinical and laboratory features, and the entire course of the disease from the onset of the symptoms is described, together with an adequate follow- up over a 7-years treatment period. In this case, the not specificity and the limited clinical relevance of the symptoms led to a delay in diagnosis. After thrombosis, Eculizumab therapy has been shown to be effective, and during seven years of followup no events have occurred that put the patient’s life at risk. A multidisciplinary approach is crucial in cases like this, in order to allow early diagnosis and minimize the risks for the patients.

Superior Mesenteric Vein Thrombosis Associated with Hormonal Contraceptive Use

A 44-year-old woman was admitted with a 7-day history of lower abdominal pain and nausea. Physical examination demonstrated tenderness in the lower abdomen without signs of peritonitis. There were no specific findings in the laboratory evaluation. She had a history of dysmenorrhea for 15 years and was taking a combined hormonal contraceptive containing 0.02 mg ethinyl estradiol and 3 mg drospirenone for 19 months. Contrast-enhanced computed tomography showed superior mesenteric vein thrombosis (SMVT). Systemic anticoagulant infusion was immediately administered and the symptoms disappeared within 2 days. The thrombus disappeared after 3 months. This case report suggests that early diagnosis of SMVT and immediate systemic anticoagulant therapy may reduce the rate of intestinal infarction.

Clinical Presentation and Outcome of Mesenteric Vein Thrombosis

Mesenteric venous thrombosis (MVT) is an uncommon event. We retrospectively analyzed data for patients who were admitted with MVT between June 2005 and May 2012 in Qatar. The study included 35 patients with a mean age of 45 ± 11 years. The risk of MVT was significantly high among males who smoked and females of Arab ethnicity. The main manifestations of MVT were abdominal distension and vomiting. The major etiological factors included deficiency in protein C and S, homocysteinemia, and prior abdominal surgery. Computed tomography (CT) findings were helpful in 80% of the patients. Bowel resection with primary anastomosis was performed in 25 (71%) patients. The overall mortality rate was 17%. High index of suspicion, detection of risk factors, CT imaging, and timely intervention are essential for better prognosis.

Portal Vein Thrombosis: A Rare Finding in a Noncirrhotic Patient

Portal vein thrombosis (PVT) is a rare cause of abdominal pain, typically associated with cirrhosis or thrombophilia. A 18-year-old female presented with abdominal pain for 10 weeks. The diagnosis was confirmed with contrast-enhanced computed tomography (CECT) abdomen after an ultrasound showed dilated and obstructed portal vein. This unexpected finding prompted investigation for intrinsic hepatic disease and potential hypercoagulable disorders. Laboratory analysis revealed an elevated serum homocysteine level, an identified risk factor for venous thrombosis. Current literature describes the following factors as indications for anticoagulation: acute thrombus, lack of cavernous transformation, absence of esophageal varices and mesenteric venous thrombosis. PVT is an uncommon cause of abdominal pain, and in the absence of hepatic disease should raise the index of suspicion for an underlying thrombophilia.

How to cite this article: Sahoo AK, Rauta S, Mohapatra SC. Portal Vein Thrombosis: A Rare Finding in a Noncirrhotic Patient. Euroasian J Hepato-Gastroenterol 2014;4(1):55-57.

[Acute mesenteric ischemia: analysis of cases over a ten-years period (2001-2010)]

Acute mesenteric ischemia is a rare disorder; it occurs on average of 0.4% of acute surgery cases. Its diagnosis is often difficult because of the poor symptoms, and mortality of the patients is still as high as 70-90%.

AIMS

The aims of the study were to assess the importance of time factor that may influence the outcome and to find out whether it is possible to decrease the high mortality rate in this disease.

METHOD

Among patients admitted to Saint Pantaleon Hospital in Hungary between January 2001 and December 2010, patients whose surgery or autopsy findings confirmed intestinal necrosis were analyzed. A total of 114 patients with acute mesenteric ischemia were included in the study.

RESULTS

55% of the patients had typical symptoms. 43.8% of the patients underwent surgery and among these patients the mortality rate was 70% despite surgical intervention. The survival rate was 72.3% when surgery was performed within less than 12 hours after the onset of symptoms, but only 20% of patients survived when surgery was delayed between 24 and 48 hours after the onset of symptoms.

CONCLUSION

With early diagnosis and intervention, patients with acute mesenteric ischemia may have a better a chance to survive.

Mesenteric Venous Thrombosis With Bowel Infarction and Hyperhomocysteinemia Due to Homozygous Methylenetetrahydrofolate Reductase C677T Genotype

The case of a 30-year-old man with bowel infarction due to mesenteric venous thrombosis and multiple risk factors, including mild hyperhomocysteinemia due to methylenetetrahydrofolate reductase C677T polymorphism and recent abdominal surgery, is reported. His clinical manifestation consisted of persistent abdominal pain; complementary examinations showed nonspecific findings such as leukocytosis and dilated loops of the bowel. The diagnosis of mesenteric venous thrombosis with bowel infarction was made during laparotomy and confirmed by anatomopathologic examination. He underwent segmental resection associated with lifelong anticoagulant therapy and vitamin B supplementation with a favorable course.

Idiopathic mesenteric venous thrombosis: report of a case

INTRODUCTION

Idiopathic mesenteric venous thrombosis is a rare entity. An early diagnosis and thrombolytic and anticoagulant therapy are very important.

PATIENT AND METHODS

We report a case of a patient, without any specific known risk factor, with small intestinal ischemia secondary to superior mesenteric vein thrombosis (SMVT).

RESULTS

In our case, only a computed tomography (CT) abdominal scan permitted the diagnosis of SMVT. The patient was successfully treated by resection of the infarcted bowel with primary anastomosis and immediate postoperative anticoagulation.

CONCLUSIONS

Diagnosis of intestinal ischemia from mesenteric venous thrombosis (MVT) is often delayed because the symptoms are nonspecific. Moreover, when there is not any known predisposing factor, the diagnosis may become even more difficult with significant morbidity and mortality. CT abdominal scan done early in case of nonspecific abdominal pain, since the patients had a previous history of venous thrombosis, may not require a surgical treatment of MVT.

Mesenteric vein thrombosis in a pregnant patient heterozygous for the factor V (1691 G --> A) Leiden mutation

Factor V Leiden mutation is a risk factor for the development of thromboembolic events in pregnancy. Thrombosis of the mesenteric vein is a fairly infrequent condition complicating pregnancy. In this paper, we described a pregnant patient with mesenteric vein thrombosis who was heterozygous for the factor V Leiden mutation.

Long-term follow-up of partial thrombosis of the superior mesenteric vein in a cirrhotic patient with hepatocellular carcinoma: a case report

Superior mesenteric venous thrombosis (SMVT) is an uncommon but potentially life-threatening disorder. We describe a cirrhotic patient with hepatocellular carcinoma who had partial SMVT for at least 28 months. Our experience may help in the management of such patients. The partial SMVT was not treated at the time of discovery because there was no evidence of bowel infarction. Moreover, the patient had a tendency to bleed severely and was in a poor condition. SMVT was followed using regular ultrasonography and the pattern of SMVT did not change significantly during the follow-up period. A symptom that may have been related to SMVT was abdominal colic pain after meals, which was sometimes followed by diarrhea and / or nausea and vomiting. There was no evidence of bowel ischemia or infarction during follow-up. Abdominal discomfort can be successfully treated using anticholinergic drugs with or without analgesia.

Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia

Major breakthroughs in catheter, guidewire, and other angiographic equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. Similarly, the interventional radiologist can treat acute intestinal ischemia safely and effectively with selective catheterization and papaverine administration and treat chronic mesenteric ischemia by percutaneous angioplasty and stent placement. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is critical in managing GI bleeding and intestinal ischemia, particularly in patients at high risk or presenting as diagnostic dilemmas.