A case of infarction of small bowel caused by thrombophilia secondary to hyperhomocysteinaemia

Abstract

Dear Editor: Patients with coronary heart disease, stroke, peripheral arterial occlusive disease or venous thrombosis show a higher prevalence of hyperhomocysteinaemia (HHCY), between 20% and 50%. The meta-analysis of Homocysteine Studies Collaboration underlines the connection between HHCY and degenerative vascular disease. For a homocysteine (HCY) increase of 5 μmol/l, the odds ratio for ischemic heart disease was calculated to be 1.32, for venous thrombosis 1.60, and 1.59 for stroke. Bostom et al. demonstrate that starting from a plasma concentration threshold of 10 μmol/l, the vascular risk progressively increases following a linear dose-response relationship. We report a case of mesenteric vein thrombosis (MVT) with segmental transmural intestinal infarction of small bowel secondary to HHCY associated with portal vein thrombosis (PVT) at 1 month from the infarct onset. A 45-year-old man was admitted for diffuse colicky abdominal pain dating back to the previous 8 days. The pain progressively worsened particularly in the lower abdominal quadrants and became continuous at admission time. The patient was affected by mild hypertension which was not on medication. The clinical history was characterized by a splenectomy performed 2 months before for a voluminous splenic organized hematoma due to a motorcycle accident. Before splenectomy the patient underwent a MR and a CT scan, which did not show any alteration in the extrahepatic portal system. Moreover, since at discharge the platelet count was within normal limits, the patient was not treated with antiplatelet agents (dipyridamole, aspirin), but only with low-molecular-weight heparin (LMWH), that he carried out until the 30th post-operative day from splenectomy. On examination, the abdomen was tender and guarded. Plain abdominal film showed some small air-fluid levels and the abdominal ultrasonography revealed significant intraperitoneal fluid and no alteration of other abdominal organs, with no evidence of PVT. Laboratory tests showed a neutrophilic hyperleukocytosis. Because of the clinical, radiological, and laboratory findings, we decided for an emergency laparotomy. Intraoperatively, 28 cm of nonviable infarcted small bowel distal to the mid-jejunum with thickened mesentery was detected. No mechanical factors or strangulation were identified. The infarcted segment was resected but bowel continuity was not restored because of the severe intestinal conditions. Therefore, a terminal ileostomy was performed. The histological report showed an acute hemorrhagic necrosis of the intestinal loop involved. Immediately after the surgical approach, the patient was put on infusion, broad-spectrum antibiotics, and anticoagulant therapy with LMWH. The intraoperative findings and the patient’s young age, associated with the lack of anamnestic cardiovascular or thrombotic risk factors, suggested us to test the patient for coagulation disorders. The screening for primary thrombophilia was only significant for a raised serum HCY of 37 μmol/l. In the review by Herrmann et al., this value is classified as intermediary HHCY and it consists of heterozygous mutations of enzymes or severe vitamin Int J Colorectal Dis (2009) 24:1471–1473 DOI 10.1007/s00384-009-0729-8