Rare Case of Isolated Mesenteric Vein Thrombosis Triggered by Acute Pancreatitis

Abstract

Introduction: Mesenteric vein thrombosis(MVT) is an uncommon cause of acute mesenteric ischemia accounting for 5 % of cases. Acute pancreatitis is associated with thrombosis of the splenic or portal vein but rarely with SMV in isolation, especially in the absence of necrosis.We describe an unusual case of isolated SMVT triggered by an episode of acute pancreatitis, found to have underlying antiphospholipid syndrome (APS). Case: 68 y/o lady w/PMH of HTN,HLP presented with diffuse intermittent abdominal pain, 7 days duration associated with multiple episodes of vomiting. She denied any fever or chills, her BMs were soft and regular without blood. On exam, vitals were stable, epigastrium was tender without rebound and BS were reduced. CBC, CMP were normal. Lipase was mildly elevated. CT abdomen showed inflammatory changes along pancreatic head & around SMV with thrombosis, concentric wall thickening along jejunum and ileum corresponding to the distribution of SMV. On review of history, her two sisters had DVT and she had h/o 2 spontaneous abortions. Anticoagulation was started with heparin and she was managed conservatively with serial abdominal exams. EGD revealed normal mucosa till mid jejunum. Hypercoagulable work up revealed elevated B2 glycoprotein IgM and positive ANA. Factor V leiden mutation and Jak 2 v617f mutation was negative. Diagnosis of antiphospholipid syndrome was made and she was discharged on oral warfarin with INR 2.0-3.0. Discussion: MVT is a rare cause of intestinal ischemia however has better prognosis than the other causes.Abdominal pain is the most common presenting symptom.Local inflammatory conditions (acute pancreatitis etc), inherited or acquired thrombophilias are predisposing factors. Diagnosis is made with demonstration of occlusion on imaging (CT or MRI).Our case is unique as isolated MVT was precipitated by acute pancreatitis; very rare in the absence of necrosis.In such cases, testing for inherited or acquired thrombophilias should be done.In our case, we found e/o elevated anti-B2 microglobulin IgMAb (persisted after 12 weeks) consistent with APS.Treatment is conservative with anticoagulation. Surgical exploration is reserved for cases with bowel infarction. Conclusion: In conclusion, our case demonstrates the need for high index of suspicion to diagnose MVT as delay in treatment is associated with poor prognosis. It also stresses the need to test for inherited or acquired thrombophilias, as it changes long term management.Figure 1