Superior mesenteric vein thrombosis: computed tomography diagnosis

Mesenteric Ischemia and Its Need for Timely Recognition and Management

Mesenteric ischemia is a fatal vascular emergency of the small intestine which, if not diagnosed and treated in time, has a very high mortality rate. Presenting with nonspecific symptoms such as abdominal pain, nausea, constipation, tachycardia, and gastrointestinal bleeds, it can masquerade as other causes of acute abdomen, particularly bowel obstruction. Ideal laboratory tests and markers are still lacking due to complexity in bowel's anatomy, physiology, blood supply, and drainage. We report 10 cases of mesenteric ischemia presented in our center with their demography, laboratory findings, approach to diagnosis, and treatment along with their outcomes at discharge. Out of the ten cases, six cases presented with signs and symptoms of acute bowel obstruction without passage of stool and one with passage of black stool. These seven patients underwent laparotomy, while the remaining three cases who either presented with milder symptoms or refused surgical interventions were managed conservatively. All patients were diagnosed with either acute or chronic mesenteric ischemia based on their operative and/or radiographic findings.

[Superior mesenteric vein thrombosis complicating an unrecognized appendicitis]

La thrombose veineuse mésentérique supérieure (TVMS) peut se présenter selon un mode aigu, subaigu ou chronique. Réputée rare, elle peut être primitive ou secondaire. Les étiologies chirurgicales les plus fréquemment identifiées de TVMS sont la diverticulite colique et l'appendicite aiguë. Les auteurs ont jugé utile de rapporter une observation de TVMS compliquant une appendicite refroidie par les antibiotiques, tout en insistant sur la latence clinique de telle pathologie rendant son diagnostic et son traitement plus difficile.

Acute mesenteric ischemia after cardio-pulmonary bypass surgery

Acute mesenteric ischemia (AMI) is a highly-lethal surgical emergency. Several pathophysiologic events (arterial obstruction, venous thrombosis and diffuse vasospasm) lead to a sudden decrease in mesenteric blood flow. Ischemia/reperfusion syndrome of the intestine is responsible for systemic abnormalities, leading to multi-organ failure and death. Early diagnosis is difficult because the clinical presentation is subtle, and the biological and radiological diagnostic tools lack sensitivity and specificity. Therapeutic options vary from conservative resuscitation, medical treatment, endovascular techniques and surgical resection and revascularization. A high index of suspicion is required for diagnosis, and prompt treatment is the only hope of reducing the mortality rate. Studies are in progress to provide more accurate diagnostic tools for early diagnosis. AMI can complicate the post-operative course of patients following cardio-pulmonary bypass (CPB). Several factors contribute to the systemic hypo-perfusion state, which is the most frequent pathophysiologic event. In this particular setting, the clinical presentation of AMI can be misleading, while the laboratory and radiological diagnostic tests often produce inconclusive results. The management strategies are controversial, but early treatment is critical for saving lives. Based on the experience of our team, we consider prompt exploratory laparotomy, irrespective of the results of the diagnostic tests, is the only way to provide objective assessment and adequate treatment, leading to dramatic reduction in the mortality rate.

[Acute superior mesenteric vein thrombosis. A retrospective study of 9 patients]

AIM OF THE STUDY

To determine diagnostic modalities and both immediate and long-term treatment of superior mesenteric venous thrombosis.

PATIENTS AND METHODS

Retrospective study from 1997 to 2004 in two institutions concerning patients with superior mesenteric vein thrombosis.

RESULTS

Nine patients (all males, mean age=55 years), were included. Abdominal pain (100%), vomiting (44%), and bowel activity disorders (44%) were the most common symptoms. A personal or familial thrombosis history was present in 67% of patients. A genetic predisposing factor of thrombosis was present in 78% of patients. The diagnosis was established with CT-scan in 8 cases with a mean delay of 8 days. Treatment was exclusively medical in 33% of patients and included surgery in 67%. All operated patients underwent resection for bowel infarction and only one had immediate anastomosis. All enterostomies were subsequently closed. No patient died.

CONCLUSION

Diagnosis of superior mesenteric vein thrombosis is frequently delayed and relies on CT-scan with intravenous contrast. Prognosis is globally favourable but depends on early application of anticoagulation therapy. In case of surgery, bowel-sparing resection is indicated and enterostomies are often needed. Genetic disorders predisposing to thrombosis are very frequent, that may indicate prolonged even definitive anticoagulation therapy.

[Mesenteric venous thrombosis: early diagnosis with abdominal CT scan and screening for coagulopathies. Six observations]

PURPOSE

Mesenteric venous thrombosis is an uncommon entity whose diagnosis is difficult because the symptoms are nonspecific. Yet early recognition of this disease helps avoid the evolution towards mesenteric infarction.

METHODS

We describe clinical symptoms and hypercoagulable states discovered in six patients with superior mesenteric venous thrombosis.

RESULTS

Five of six patients were admitted to hospital for abdominal pain whose mean duration was 9 days before the diagnosis of venous thrombosis was made. Three of them had a fever. Two patients had a past history of deep venous thrombosis. All patients had a hypercoagulable state and three of them had two associated disorders of coagulation. In all cases, abdominal CT scan had permitted the diagnosis of mesenteric venous thrombosis. An anticoagulant therapy was conducted successfully in five of six patients.

CONCLUSION

A CT abdominal scan done early in the case of nonspecific abdominal pain, since the patients had a previous history of venous thrombosis, may permit a nonsurgical treatment of mesenteric venous thrombosis. A screening for thrombophilia must always be carried out since coagulation disorders are very frequently the recognised causes in mesenteric venous thrombosis.