The risk of developing splanchnic vein thrombosis in acute pancreatitis increases 3 days after symptom onset: A systematic review and meta-analysis

BACKGROUND

Splanchnic vein thrombosis is a complication of acute pancreatitis (AP) and is likely often underdiagnosed.

OBJECTIVES

We aimed to understand the time course and risk factors of splanchnic vein thrombosis in the early phase of AP.

METHODS

A systematic search was conducted using the PRISMA guidelines (PROSPERO registration CRD42022367578). Inclusion criteria were appropriate imaging techniques in adult AP patients, studies that reported splanchnic vein thrombosis data from the early phase, and reliable information on the timing of imaging in relation to the onset of pancreatitis symptoms or hospital admission. The proportion of patients with thrombosis with 95% confidence intervals (CI) was calculated using random-effects meta-analyses, and multiple subgroup analyses were performed.

RESULTS

Data from 1951 patients from 14 studies were analyzed. The proportion of patients with splanchnic vein thrombosis within 12 days after symptom onset was 0.13 (CI 0.07-0.23). The occurrence was lowest at 0.06 (CI 0.03-0.1) between 0 and 3 days after symptom onset, and increased fourfold to 0.23 (CI 0.16-0.31) between 3 and 11 days. On hospital admission, the proportion of patients affected was 0.12 (CI 0.02-0.49); it was 0.17 (CI 0.03-0.58) 1-5 days after admission. The prevalence in mild, moderate, and severe AP was 0.15 (CI 0.05-0.36), 0.26 (CI 0.15-0.43), and 0.27 (CI 0.17-0.4), respectively. Alcoholic etiology (0.31, CI 0.13-0.58) and pancreatic necrosis (0.55, CI 0.29-0.78, necrosis above 30%) correlated with increased SVT prevalence.

CONCLUSION

The risk of developing splanchnic vein thrombosis is significant in the early stages of AP and may affect up to a quarter of patients. Alcoholic etiology, pancreatic necrosis, and severity may increase the prevalence of splanchnic vein thrombosis.

Successful Multimodal Treatment of Pancreatic Cancer With Extensive Superior Mesenteric Vein Thrombosis Utilizing Chemotherapy Combined With Direct Oral Anticoagulant

It is well known that portal vein thrombosis (PVT) sometimes occurs in pancreatic cancer (PC). However, no effective treatment plan for PVT in PC patients has yet been proposed. We experienced a successfully treated case of borderline resectable pancreatic cancer (PC-BR) with extensive superior mesenteric vein thrombosis utilizing intensive chemotherapy combined with direct oral anticoagulant. The thrombus disappeared and the tumor shrank, enabling curative surgery, and long-term survival for more than five years has been achieved. We report this successful case that we experienced as an option for the treatment of PC-BR with PVT in the future era when multimodal treatment is important.

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.

Case Report: PROS1 (p.Leu584Arg) pathogenic mutation causes portal and superior mesenteric venous thromboembolism

Background

Genetic and acquired risk factors are fundamental to developing venous thromboembolism. Autosomal dominant protein S deficiency caused by pathogenic mutations in the PROS1 gene is a well-known risk factor for thrombophilia.

Case presentation

We report a 30-year-old male patient who presented to the hospital with portal vein thrombosis. The patient had a history of abdominal pain for one month. Abdominal vascular CT showed venous thrombosis in the portal vein and superior mesenteric vein. He was diagnosed with "portal and superior mesenteric vein thrombosis, small bowel obstruction and necrosis, acute upper gastrointestinal bleeding (UGIB), hemorrhagic shock." Serum protein S levels were decreased, and gene sequencing revealed a heterozygous missense mutation in PROS1, c.1571T > G (p.Leu584Arg). The patient received anticoagulation therapy with Enoxaparin Sodium and rivaroxaban, transjugular intrahepatic portosystemic shunt (TIPS), and ICU treatments. Although the patient had a severe bleeding event during anticoagulation therapy, he recovered well after active treatment and dynamic monitoring of anti-Xa.

Conclusion

Hereditary protein S deficiency caused by a mutation in the PROS1 gene is the genetic basis of this patient, and Enoxaparin Sodium and rivaroxaban have been shown to be highly effective.

Multiple Thrombotic, Infectious, and Cardiopulmonary Complications Following Laparoscopic Converted to Open Colectomy Procedure: A Case Report and Literature Review

All surgeries, from minor procedures, such as sutures, to major surgeries, such as open abdominal surgery, carry with them risk for complications. Among the most frequently encountered complications are surgical site infections and thrombotic complications. Less frequently, cardiac complications such as atrial fibrillation are seen. In this case report, we discuss the various complications encountered during the hospital stay of a 61-year-old male following a laparoscopic converted to open colectomy procedure for the treatment of a colorectal mass. Following surgery, a surgical pathology report revealed a newly diagnosed stage 3b colorectal adenocarcinoma. Multiple abscesses in the abdominopelvic cavity were discovered on computed tomography (CT), revealing a major surgical site infectious process. These findings warranted emergent surgical intervention and placement of multiple Jackson-Pratt drains. Due to previously untreated carcinoma promoting a prothrombotic state, the patient developed numerous thrombotic complications such as segmental pulmonary embolism, superior mesenteric vein thrombosis, and superficial thrombophlebitis of the saphenous veins. He also developed new-onset paroxysmal atrial fibrillation secondary to postoperative pain, as well as bilateral pleural effusions. Here, we shed light on the mechanisms of development of such complications, as well as the management and methods for prevention.

Acute mesenteric ischemia secondary to superior mesenteric vein thrombosis in a patient with liver cirrhosis: A case report

RATIONALE

Acute mesenteric ischemia due to superior mesenteric vein (SMV) thrombosis is a rare yet potentially life-threatening emergency. Our case report explores this condition in the context of a patient with liver cirrhosis due to Wilson disease. We specifically highlight the complex derangement of the coagulative balance in liver cirrhosis.

PATIENT CONCERNS

A 34-year-old female with Wilson disease-related cirrhosis presented with intractable abdominal pain, nausea, and vomiting that showed no response to antispasmodic medication.

DIAGNOSES

A contrast-enhanced abdominal computed tomography scan and Doppler ultrasound confirmed an intraluminal filling defect in the SMV, leading to the diagnosis of SMV thrombosis.

INTERVENTIONS

Prompt anticoagulation, intravenous fluids, and an antibiotic were initiated. Surgical consultation recommended conservative therapy with close monitoring.

OUTCOMES

Over the following 2 days, the patient's condition improved considerably, with almost complete resolution of her symptoms. Genetic testing identified a 4G/4G homozygous genotype of the plasminogen activator inhibitor 1 gene, associated with a higher risk of thrombosis in the vessels of internal organs. After 2 months of sustained anticoagulant therapy, a follow-up contrast-enhanced computed tomography scan revealed near-complete recanalization of the SMV, and the patient remained symptom-free.

LESSONS

This case underscores the importance of early detection and treatment of acute mesenteric ischemia in patients with liver cirrhosis, as well as the potential role of genetic factors in thrombosis.

A Case of Loss of Consciousness Due to Thrombosis of the Inferior Vena Cava and Portal Vein

We present a case where intraperitoneal venous thrombosis was difficult to treat. It is difficult to suspect intraperitoneal venous thrombosis in patients who have visited the hospital due to loss of consciousness, and it is necessary to administer anticoagulants early for treatment and to determine the appropriate timing for surgical intervention. The patient was a 78-year-old male who independently performed his daily activities. On the day of admission, he lost consciousness and was brought to our hospital. Computed tomography (CT) angiography revealed thrombi from the inferior vena cava and portal vein to the superior mesenteric vein, and the patient was started on anticoagulant therapy. The CT angiography images on day 7 of the illness revealed that the thrombus in the superior mesenteric vein expanded to the caudal side. Intestinal necrosis occurred on day 22 of the illness, and emergency laparotomy was performed. The chosen course of treatment was successful, and the patient was discharged on the 48th day.

Acute Portal Vein Thrombosis as an Initial Presentation of Protein C Deficiency: A Case Report

Protein C (PC) is an essential vitamin K-dependent protein that regulates thrombosis and hemostasis in the body. A mutation in the PROC gene on chromosome 2q14.3 results in PC deficiency. The clinical presentation of PC deficiency can vary, ranging from a single vein thrombosis to disseminated intravascular coagulation, purpura fulminans, or even life-threatening complications such as sepsis. Here, we present a case of a 37-year-old female who was found to have acute portal vein thrombosis as an initial presentation of PC deficiency. She presented to the hospital with acute onset of abdominal pain associated with nausea, blood-streaked emesis, and bloody bowel movement.

Severe superior mesenteric vein thrombosis after COVID-19 mRNA vaccination

Venous thrombosis is a rare occurrence following the administration of the COVID-19 mRNA vaccine. The occurrence of superior mesenteric vein (SMV) is even more rare. SMV thrombosis should be considered as a differential diagnosis in patients who develop abdominal pain after COVID-19 mRNA vaccination.

Hypercoagulable Factors Attributing to Superior Mesenteric Vein Thrombosis and Acute Mesenteric Ischemia

Acute mesenteric ischemia is rare and can be difficult to diagnose due to vague symptoms often endorsed by patients. It can be fatal if not discovered in time, as it can lead to bowel ischemia, sepsis, and ultimately death. Here, we present a case of a 23-year-old female with hepatic steatosis, obesity, and 5-year history of birth control use who developed acute mesenteric ischemia secondary to superior mesenteric venous (SMV) thrombosis, requiring small bowel resection of 238 cm out of 480 cm (49.5%) after delay in diagnosis. Hypercoagulable and genetic workup during admission later revealed heterozygous factor V Leiden (FVL) mutation. The patient was ultimately discharged to inpatient rehabilitation on anticoagulation.

Pylephlebitis: A Rare Complication of Acute Appendicitis

Pylephlebitis is defined as an infective suppurative thrombosis of the portal vein and its tributaries - a rare complication of intra-abdominal infections. It is most commonly seen in patients with diverticulitis and appendicitis. Prompt diagnosis with abdominal ultrasound and computerized tomography (CT) scan along with early and aggressive treatment with broad-spectrum antibiotics is crucial because of its high mortality rates. However, this diagnosis is often missed due to the nature of its nonspecific clinical symptoms. We discuss a case of a 22-year-old male who presented with pylephlebitis as a complication of acute gangrenous appendicitis. The patient was treated successfully with appropriate surgical intervention, antibiotics, and anticoagulation.

Acute Mesenteric Ischemia Secondary to Superior Mesenteric Vein Thrombosis

The thrombosis of the superior mesenteric vein (SMV) can result in ischemia of the intestine. A 71-year-old male presented with pain in the abdomen and a black tarry stool. The findings from computed tomography (CT) with the contrast of the abdomen suggest the thrombosis of the SMV. Heparin was administered, followed by thrombectomy and stenting of the SMV. The patient reported no complications and was shifted from heparin to apixaban and then discharged after a five-day hospital stay.

Septic Portal Vein Thrombosis, Clinical Presentation, and Management

Pylephlebitis, otherwise known as septic portal vein thrombosis, is an infective suppurative thrombosis of the portal vein and/or its intra-hepatic branches. It is a diagnosis that is frequently missed but easily treated with antibiotics. Therefore, it should be considered early on in any patient presenting with fever, abdominal pain, leukocytosis, and evidence of portal vein thrombosis on a CT scan. In this case report, we discuss a case of pylephlebitis as well as the etiologies, diagnosis, and treatment of septic portal vein thrombosis.

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

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

t-PA power-pulse spray with rheolytic mechanical thrombectomy using cross-sectional image-guided portal vein access for single setting treatment of subacute superior mesenteric vein thrombosis

Background:

Isolated superior mesenteric vein (SMV) thrombosis is a rare but potentially fatal condition if untreated. Current treatments include transjugular or transhepatic approaches for rheolytic mechanical thrombectomy and subsequent infusions of thrombolytics. Tissue plasminogen activator (t-PA) power-pulse spray can provide benefit in a single setting without thrombolytic infusions. Computed tomography (CT) guidance for portal vein access is underutilized in this setting.

Materials and Methods:

Case 1 discusses acute SMV thrombosis treated with rheolytic mechanical thrombectomy alone using ultrasound guidance for portal vein access. Case 2 discusses subacute SMV thrombosis treated with the addition of t-PA power-pulse spray to the rheolytic mechanical thrombectomy, using CT guidance for portal vein access.

Results:

With rheolytic mechanical thrombectomy alone, the patient in Case 1 had significant improvement in abdominal pain. Follow-up CT demonstrated no residual SMV thrombosis and the patient continued to do well in long-term follow-up. With the addition of t-PA power-pulse spray to rheolytic mechanical thrombectomy, the patient in Case 2 with subacute SMV thrombosis dramatically improved postprocedure with resolution of abdominal pain. Follow-up imaging demonstrated patency to the SMV and partial resolution of thrombus. The patient continued to do well at 2-year follow-up.

Conclusions:

Adding t-PA power-pulse spray to rheolytic mechanical thrombectomy can provide benefit in a single setting versus mechanical thrombectomy alone and prevent the need for subsequent infusions of thrombolytic therapy. CT guidance is a useful alternative of localization for portal vein access via the transhepatic route that is nonoperator-dependent and helpful in the case of obese patients.

Thrombosis of the Portal Vein and Superior Mesenteric Vein in a Patient With Subclinical COVID-19 Infection

More than 122 million cases of COVID-19 infection have been documented, and hundreds of thousands are being added every day. Several co-morbidities are associated with COVID-19, among which hypercoagulability has garnered the attention of many doctors and researchers. Most cases of vascular thrombosis are noted in intensive care unit (ICU) patients with serious disease; among these, many cases of deep venous thrombosis and pulmonary embolism have been noted. A few cases of portal vein thrombosis have also been documented in ICU patients with severe COVID-19. Here, we present a case of a portal vein and superior mesenteric vein thrombosis in a patient with subclinical COVID-19 infection. Through this case report, we intend to increase the research horizon and wish to help diagnose co-morbidities associated with COVID-19 at an earlier stage.

Hepatocellular Carcinoma With Extensive Cancer-associated Thrombosis Successfully Treated With Liver Resection and Direct Oral Anticoagulant: A Case Report

AIM

To assess the utility of the perioperative use of direct oral anticoagulants for patients with hepatocellular carcinoma (HCC) with cancer-associated thrombosis.

CASE REPORT

An 83-year-old woman was admitted with a solitary HCC (10-cm diameter), as well as with multiple sites of venous thromboembolism and macroscopic portal vein tumor thrombosis. She had appropriate liver function without viral hepatitis, triple-positive tumor markers, and secondary polycythemia. Edoxaban at 30 mg was initiated 10 days before surgery to remove HCC. Complete remission of the pulmonary embolism and stability of the deep vein thrombosis and massive superior mesenteric vein thrombosis were recognized preoperatively. An extended left hepatectomy was successfully performed. To avoid hemorrhage complications, we used intravenous administration of nafamostat mesylate for 2 days, thereafter we restarted edoxaban. Superior mesenteric vein thrombosis resolved 5 months after surgery.

CONCLUSION

Perioperative oral administration of edoxaban was useful in multidisciplinary treatment for a patient with advanced HCC with cancer-associated thrombosis.

Mesenteric venous thrombosis as a complication of appendicitis in an adolescent: A case report and literature review

RATIONALE

Mesenteric venous thrombosis is an uncommon but potentially fatal condition that can cause bowel ischemia. It results from a systemic hypercoagulable state or abdominal infection draining into the portal venous system. Several cases regarding portomesenteric venous thrombosis as a complication of appendicitis were reported in adults, but there are far fewer reports in pediatric patients. The mortality rate of the condition is high if untreated, especially in children, reaching up to 50%.

PATIENT CONCERNS

A healthy 15-year-old male with no significant past medical history presented with right lower quadrant pain, lethargy, and fever. The computed tomography scan showed a focal thrombosis at the superior mesenteric vein branch and an inflamed appendix.

DIAGNOSES

Mesenteric venous thrombosis complicating acute appendicitis.

INTERVENTIONS

Intravenous antibiotics along with anticoagulants and laparoscopic appendectomy OUTCOMES:: After 1 month, a follow-up ultrasonography revealed full resolution of the thrombosis.

LESSONS

Appendicitis is one of the most frequently encountered causes of pediatric surgical emergencies; therefore, physicians should be conscious of mesenteric venous thrombosis as a possible complication of acute appendicitis, irrespective of whether patients have thrombophilic conditions or not.

Superior mesenteric venous thrombosis complicating acute appendicitis: A case report

RATIONALE

Superior mesenteric venous thrombosis (SMVT) is a rare condition that carries high mortality. Very few cases have been reported of SMVT, complicating acute appendicitis. Early recognition requires a high index of suspicion and is crucial in successful treatment of such a life-threatening condition.

PATIENT CONCERNS

A 33-year-old male presents with a 4-day history of right lower abdominal pain, nausea and subjective fever. CT scan showed acute appendicitis and a central filling defect in the superior mesenteric vein.

DIAGNOSES

Acute appendicitis complicated by SMVT.

INTERVENTIONS

Intravenous antibiotics, appendectomy, and anticoagulation.

OUTCOMES

Repeat CT scan showed successful resolution of the SMVT at a 3-month follow up.

LESSONS

Clinical awareness and high index of suspicion are essential to diagnose and manage SMVT, a serious complication of acute appendicitis.

Congenital Thrombophilia in Patients With Superior Mesenteric Venous Thrombosis or Portal Vein Thrombosis

We explored the relationship between abdominal vein thromboses, including portal vein thrombosis (PVT) and superior mesenteric vein thrombosis (SMVT), and thrombophilia. The frequency of thrombophilia, such as antithrombin (AT), protein C (PC), or protein S (PS) gene mutations, was examined in 21 patients with PVT, 6 patients with SMVT, and 6 patients with both PVT and SMVT. Low levels of AT, PC, or PS were frequently detected in patients with PVT or mesenteric vein thrombosis, and 4 mutations in the PS gene, 3 mutations in the PC gene, and 2 mutations in AT the gene were detected. Protein S Tokushima was detected in 3 of 4 patients with a PS gene mutation and was associated with 2 other PS gene mutations. The onset of PVT or SMVT was almost idiopathic in patients with congenital thrombophilia. Both PVT and SMVT were frequently caused by an AT, a PC, or a PS mutation, and the onset of these thromboses due to thrombophilia was frequently idiopathic.

Liver Abscess and Portal Vein Thrombosis Due to Ileal Diverticulitis Mediated by Barium Fluoroscopy

We report a case of liver abscess and portal vein thrombosis, which occurred due to diverticulitis at the terminal ileum in a 59-year-old man. The patient underwent a barium fluoroscopic examination 1 month before presenting to our hospital. He also showed liver dysfunction due to thrombosis at the superior mesenteric and portal veins. His inflammation gradually subsided after the initiation of treatment, but the recovery was not sufficient. Thus, surgery was performed. The patient condition improved after surgery and he was discharged. Barium examinations are relatively safe, but can sometimes cause severe adverse effects in patients with certain risk factors, and an appropriate diagnosis and treatment are necessary when symptoms appear.

Small bowel varices secondary to chronic superior mesenteric vein thrombosis in a patient with heterozygous Factor V Leiden mutation: a case report

INTRODUCTION

Bleeding ectopic small bowel varices pose a clinical dilemma for the physician, given their diagnostic obscurity and the lack of evidence-based medicine to guide therapy. They often occur in the context of portal hypertension, secondary to either liver disease or extrahepatic causes. Rarely is their presence associated with chronic superior mesenteric vein thrombosis and hereditary coagulopathies.

CASE PRESENTATION

A 74-year-old white woman, with a heterozygous Factor V Leiden mutation and no underlying liver disease or portal hypertension, presented over the course of 13 months for recurrent episodes of melena and per rectal bleeding. An initial endoscopy showed a clean-based chronic gastric ulcer, while colonoscopies showed multiple, non-bleeding angioectasias which were treated with argon plasma coagulation. Subsequent video capsule endoscopy and double balloon enteroscopy revealed red wale marks overlying engorged submucosal veins in her distal ileum, consistent with ectopic varices. A chronic superior mesenteric vein thrombus, found via computed tomography venogram, was the cause of the ileal varices. She underwent curative surgical resection of the affected bowel, with no re-bleeding episodes 17 months post-surgery, despite needing lifelong anticoagulation for recurrent venous thromboembolisms.

CONCLUSIONS

Clinicians should consider ectopic varices in patients who present with obscure gastrointestinal bleeding, even in the absence of portal hypertension or liver disease. In those with a known thrombophilia, patients should be screened for splanchnic thrombosis, which may precipitate ectopic varices.