S2746 Mesenteric Venous and Portal Vein Thrombosis in a Patient With Ulcerative Colitis: Delayed Post-Operative Presentation or Hypercoagulable State?

Abstract

Introduction: Mesenteric venous thrombosis (MVT) and portal vein thrombosis (PVT) are conditions involving occlusion of the vascular supply of the intestinal system. The symptoms of MVT and PVT may be nonspecific, however, patients may present with acute abdominal pain. The cause of venous thrombosis of the gastrointestinal system may be multifactorial, including patients with pro-coagulable conditions. Here we present the case of a patient with ulcerative colitis (UC) who underwent a recent colectomy with end ileostomy and arrived at the Emergency Department (ED) with acute abdominal pain secondary to superior mesenteric vein thrombosis extending into the portal vein. Case Description/Methods: This is the case of a 40-year-old male with a history of refractory ulcerative colitis diagnosed 7 years before admission, with evidence of disease on descending, sigmoid, and rectum. He underwent laparoscopic total abdominal colectomy with end ileostomy a month before admission. His symptoms were controlled with Ustekinumab and Prednisone tapering. The patient arrives at the ED with symptoms of tenesmus, generalized abdominal pain, and rectal bleeding. His physical examination was remarkable for hemodynamic stability and diffuse abdominal pain on palpation, without rebound or guarding. Abdominopelvic computed tomography with intravenous contrast revealed a large intramural thrombus extending from the superior mesenteric vein into the portal vein. The patient was started on an intravenous heparin drip, which was transitioned to direct oral anticoagulation therapy prior to discharge. Discussion: Patients with ulcerative colitis who require surgical intervention are at an increased risk of thromboembolic events. Here, we presented the case of a patient with evidence of extensive portomesenteric thrombosis with delayed onset after surgical intervention. Post-operative thrombosis is prevalent within 7-10 days after surgery. However, our patient presented with extensive thrombosis more than 1 month after the intervention. Our case raises concerns regarding the multifactorial etiology of the patient’s presentation. Moreover, UC has been known to increase prothrombotic state. Therefore, this case highlights how MVT in patients with UC may be secondary to a combination of factors, such as the hypercoagulable state of UC due to chronic inflammation and mechanical endothelial injury from surgical intervention. Prompt evaluation is essential to prevent intestinal infarction and reduce morbidity and mortality in these patients.