Abstract
A 45-year-old woman was admitted to our hospital because of acute abdominal pain in September 2000. The patient had had no relevant medical history until July 2000 when because of an upper left abdominal quadrant tenderness, splenomegaly was noted on clinical examination. A computed tomography scan (panel 1) revealed an inhomogeneous and enlarged pancreatic head (arrow) involving the mesenteric vein together with splenomegaly and ascites. A pancreatic tumour with peritoneal metastases was suspected. The patient refused further investigations. At admission to our Unit she presented a diffusely painful abdomen with rebound tenderness and increased white blood cells; an enlarged spleen with a splenic infarction was seen at ultrasonography and an emergency laparotomy was performed. The infarcted spleen was removed but no pancreatic tumour was found. A contrast enhanced magnetic resonance angiography (CE-MRA), done in the postoperative period, showed a portal and mesenteric vein thrombosis with a large portal cavernoma (panel 2A) strictly adherent to the pancreatic head with continuing thrombosis of the portal trunk (arrow). A screening for acquired and inherited thrombophilic disorders was done and anticoagulation therapy started soon after. A TT677 mutation of methylene tetrahydrofolate reductase associated with high plasma levels of homocysteine was the only thrombophilic factor found in this patient. CE-MRA is a well-established tool to assess splanchnic vessel distribution and patency [1]. It can help to diagnose portal vein thrombosis, further providing axial imaging.
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