S1426 Double Trouble: Chronic Pancreatitis and an Overlooked Superior Mesenteric Vein Thrombosis

Abstract

INTRODUCTION: Chronic pancreatitis is a challenging disease process to manage. Abdominal pain is the most common, debilitating symptom for these patients. Here, we outline the outpatient approach and management of a patient with chronic pancreatitis who also had concomitant mesenteric venous thrombosis. CASE DESCRIPTION\METHODS: A 56-year-old man with history of tonsillar squamous cell carcinoma and non-small cell lung cancer treated with radiation, coronary artery disease, heavy tobacco use, cholecystectomy, and chronic pancreatitis complicated by pseudocysts and exocrine insufficiency presented to internal medicine clinic with persistent epigastric pain. Three years ago, he was diagnosed with chronic pancreatitis, secondary to heavy alcohol and tobacco use. In the interim, he quit alcohol, reduced smoking, and went through multiple therapeutic regimens including gabapentin, opioids, pancreatic enzyme replacement, and celiac plexus block. On exam, he was hemodynamically stable but in discomfort due to pain. He was cachectic and had epigastric tenderness without rebound tenderness or guarding. Laboratory tests revealed cholestatic transaminitis. We referred him to a gastroenterologist. MRCP showed irregular contour of the pancreas with smooth narrowing in the pancreatic neck concerning for a stricture. EGD and EUS were planned. Duloxetine was added to his regimen. However, MRI revealed an occlusion of the superior mesenteric vein at the level of the portal confluence with multiple collateral vessels at the root of the mesentery. Prior CT scan showed the presence of thrombus two years ago. Medical record did not reveal any management of the thrombus and the patient was unaware of the condition. He did not have evidence of portal hypertension. Given the severity of the symptoms and lack of prior anticoagulation, we started him on rivaroxaban. Despite this intervention, he continued to have flares of chronic pancreatitis in the subsequent months and will undergo another celiac plexus block. DISCUSSION: Chronic mesenteric venous thrombosis is often an incidental finding on imaging and usually asymptomatic. This is mainly considered a consequence of venous stasis and endothelial injury, compounded by risk factors such as local inflammation (e.g., pancreatitis), abdominal tumors or pseudocysts, and acquired thrombophilia. Anticoagulation is generally recommended. In the absence of predisposing illness or a hypercoagulable state, further work-up for portal hypertension and referral to hematology are indicated.