Mesenteric Vein Thrombosis Research Articles

S2939 A Rare Case of Superior Mesenteric Vein Thrombosis With Antithrombin III Deficiency and Recent COVID-19 mRNA Vaccination

Introduction: Superior mesenteric vein (SMV) thrombosis is a condition with low incidence but high mortality. It is well-known to occur in the setting of prothrombotic states such as malignancy, local abdominal inflammation, inherited or acquired coagulopathies, and myeloproliferative conditions secondary to JAK-2 mutation. We present a rare case of SMV thrombosis in a patient found to have antithrombin III deficiency with recent COVID-19 mRNA vaccination. Case Description/Methods: A 67-year-old male with past medical history significant for hyperlipidemia and coronary artery disease presented to the emergency department with three days of intermittent lower abdominal pain radiating laterally in a band-like distribution with pressure and bloating sensation. On physical exam his abdomen was mildly distended but soft and non-tender with hypoactive bowel sounds. Computed tomography (CT) of the abdomen and pelvis with intravenous contrast revealed diffuse SMV thrombosis with extension of thrombus into the main and left hepatic portal veins. There was no clear intra-abdominal inflammatory process, no sign of infection or malignancy, and no history of inherited thrombophilia. Patient was started on therapeutic enoxaparin subcutaneously. Further history revealed that he received both doses of the Pfizer-BioNTech (BNT162b2) mRNA COVID-19 vaccine, with the second dose administered 75 days prior to admission. SARS CoV-2 IgG level was 69 AU/mL, which confirmed the presence of circulating IgG antibodies specific for SARS-CoV-2 at high levels. SARS-CoV-2 RNA was not detected on reverse-transcriptase–polymerase-chain-reaction assay of a nasopharyngeal swab. Lab work revealed low antithrombin III (AT III) at 69% and prolonged Russell’s Viper Venom test not corrected by phospholipid reagent. Discussion: It is unclear if this patient’s low ATIII levels were in the setting of acute thrombosis, or if they were low prior to thrombus formation and secondary to circulating Covid-19 antibodies. There have been a few case reports of individuals with vaccine-induced immune-thrombotic thrombocytopenia (ITTP), deep vein thrombosis (DVT), and acquired hemophilia. It is important to bring awareness to uncommon adverse events that may be linked to COVID-19 mRNA vaccine administration so that providers and patients can be aware of the possibility of these events and not delay diagnosis and treatment.Figure 1.: Computed tomography (CT) of the abdomen and pelvis revealing diffuse SMV thrombosis with adjacent fat stranding.

S1852 Colonic Varices Due to Alcoholic Cirrhosis

Introduction: Ectopic varices (all varices outside the gastroesophageal region) account for 1-5% of all variceal bleeding episodes. Specifically, colon varices are rare, as incidence of colonic varices, irrespective of etiology, is around 0.07%. If colonic varices bleed, treatment is urgent, as delay in treatment can potentially be fatal. Case description/methods: A 55 year old male with a past medical history of complicated diverticulitis status post open sigmoidectomy and heavy alcohol abuse with history of deliriums tremens who was admitted due to having hematochezia with bowel movements for two days. He denied any hematemesis, abdominal pain, melena or NSAID use. Patient was hypotensive on arrival to the ED with MAPs in the 40s. On physical exam, scleral icterus along asterixis and tremors in his hands were noted. CTA Abdomen and Pelvis showed no signs of active gastrointestinal bleeding with signs of hepatic cirrhosis with extensive esophageal, gastric varices, and descending colon varices. Patient had two more episodes of hematochezia in the ED. Patient was given 2 units of emergent blood in the ED to help stabilize his blood pressure. Patient did not have a diagnosis of cirrhosis prior to presentation. He admitted to drinking a six pack of beer daily for the past thirty years. Last colonoscopy was five years ago which showed tubular adenomatous polyps in the rectum and ascending colon. Diverticulosis was also present in the ascending colon. Patient had EGD performed which showed some mild esophagitis and some portal hypertensive gastropathy (PHG) located in the antrum, body and fundus. Flexible sigmoidoscopy was then performed which showed a large amount of fresh and old blood coming from a sigmoid varix at 25 cm located in the sigmoid colon. Hemostasis was achieved with using a Bear claw clip (Figure 1). Discussion: Colonic varices can develop secondary to portal hypertension, congenital anomalies in venous outflow, mesenteric or splenic vein thrombosis, congestive heart failure, or formation of collateral vessels from previous abdominal surgeries. Patients with suspected bleeding colonic varices need immediate assessment, resuscitation, and hemodynamic stabilization. There are no evidence based guidelines for treatment for bleeding colonic varices, but options include medical, endoscopic, interventional radiological and surgical modalities.Figure 1.: Bear claw clip was used to achieve hemostasis.

Клинический случай успешного консервативного лечения тромбоза воротной и верхней брыжеечной вен

Острый тромбоз воротной вены является потенциально опасным для жизни состоянием, представляющим значительные сложности в диагностике и выборе тактики лечения пациента. Единых рекомендаций по оказанию неотложной помощи при данной патологии не существует. В статье представлен клинический случай успешной и своевременной диагностики и лечения этого заболевания.

A case of successful treatment of pylephlebitis in a patient with acute appendicitis

Pylephlebitis is a rare and potentially lethal complication of acute appendicitis. It leads to the development of liver abscesses and sepsis. Usually, this complication is the result of late diagnosis. Only rare cases of successful treatment of pylephlebitis in the context of acute appendicitis are published in special literature. The aim of the demonstration is to analyze of the diagnosis and medical tactic mistakes as a case of pylephlebitis in a patient with acute appendicitis; show the possibilities of modern methods of diagnosis and treatment, which made it possible to achieve a success. The case of successful treatment patient with pylephlebitis was shown in the article. Late diagnosis of acute appendicitis was associated with the patient’s refusal and with some diagnostic and tactic mistakes that were analyzed. The case presented by jaundice, liver failure and fever. Thrombosis of portal vein diagnosed by U/S, CT scan with intravenous contrast on day 11 of the illness. Appendectomy was performed. Intensive care with extracorporeal therapy, antibacterial and anticoagulant therapy were also provided. Septic thrombosis of portal vein was complicated by an abscess of the right lobe of the liver and sepsis. The case of successful treatment of patient with septic thrombosis of portal vein and superior mesenteric vein complicated by liver abscess and sepsis is considered in the article. Intensive therapy, extracorporeal detoxification and abdominal abscess drainage under the U/S control have resulted in a fully repatency of portal vein that was confirmed by CT scan data.

Appendicitis with superior mesenteric vein thrombosis

A 40-year-old man presented with a 4-day history of generalized abdominal pain, vomiting, and diarrhea. He had no significant medical history or regular medications. He was febrile at 40 degrees Celsius, tachycardic at 120 beats per minute, and hypotensive with a blood pressure of 90 mm Hg systolic. He was confused and agitated. On examination, there was significant tenderness to the right iliac fossa with peritonism. Biochemistry revealed a C-reactive protein of 168 mg/L, white cell count of 5 × 109 cells, and lactate of 2.6 mmol/L. Computed tomography of the abdomen and pelvis revealed dilatation of the appendix with periappendiceal fat stranding in keeping with acute appendicitis. There was adjacent free air in keeping with perforation.

Portal vein thrombosis associated with high 14-day and 6-week rebleeding in patients after oesophageal variceal band ligation: a retrospective, multicentre, nested case–control study

The association between prognosis of variceal bleeding and portal vein thrombosis (PVT) is unclear. In this multicentre study, we determined the effect of PVT on rebleeding and mortality in patients with acute variceal bleeding (AVB) after oesophageal variceal band ligation (EVL). Cirrhotic patients with AVB who had undergone EVL were included. The patients were allocated to either the PVT group or the control cirrhotic group (CCG) based on the presence or absence of PVT. One-year rebleeding episodes and mortality after EVL were recorded. A total of 218 cirrhotic patients with AVB from 3 centres were included. Patients with PVT had a higher rate of 14-day and 6-week rebleeding than those without PVT (14-day: 8.26% vs. 1.83%, p = 0.03; 6-week: 11.92% vs. 1.83%, p = 0.003). The rates of 5-day failure (3.67% vs. 0.92%, p = 0.175), 1-year rebleeding (21.10% vs. 20.18%, p = 0.867), and 14-day, 6-week, and 1-year mortality were similar between the groups (14-day: 3.67% vs. 0.92%, p = 0.175; 6-week: 3.67% vs. 0.92%, p = 0.175; 1-year: 3.67% vs. 1.83%, p = 0.408). The Child-Pugh class [p = 0.022, hazard ratio (HR): 1.453; 95% confidence interval (CI) 1.056-1.998], PVT (p = 0.050, HR: 4.622, 95% CI 0.999-21.395), albumin < 30g/L (p = 0.023, HR: 5.886, 95% CI 1.272-27.245), and number of bands (p = 0.010, HR: 1.207, 95% CI 1.046-1.393) were identified as the predictors for 14-day rebleeding; the multivariate analysis revealed only the number of bands (p = 0.009, HR: 1.247, 95% CI 1.056-1.473) as the independent factor. PVT (p = 0.012, HR: 6.732, 95% CI 1.519-29.835) and albumin < 30g/L (p = 0.027, HR: 3.643, 95% CI 1.160-11.441) were identified as predictors for 6-week rebleeding; however, only PVT (p = 0.015, HR: 6.380, 95% CI 1.427-28.515) was found to be the independent factor in the multivariate analysis. Further analysis showed that superior mesenteric vein (SMV) thrombosis is the only risk factor predicting 6-week rebleeding in patients with PVT (p = 0.032, HR: 3.405, 95% CI 1.112-10.429). PVT was associated with high 14-day and 6-week rebleeding in patients after EVL. SMV thrombosis was the only risk factor for 6-week rebleeding in patients with PVT. High albumin levels may serve as a protective factor for the 14-day and 6-week rebleeding risk. PVT was not responsible for mortality after EVL during 1-year follow-up.

A Phase Ib Study of Isatuximab in Combination with Bortezomib, Cyclophosphamide, and Dexamethasone (VCDI) in Patients with Newly Diagnosed Multiple Myeloma Non-Eligible for Transplantation

Abstract Background: Isatuximab (ISA) is an anti-CD38 monoclonal antibody with multiple modes of action for killing tumor cells through direct tumor targeting and immune cell engagement. It has demonstrated strong potentiation when combined with bortezomib in a multiple myeloma (MM) xenograft model (Deckert J et al, Clin Cancer Res 2014:20:4754). The combination of bortezomib, cyclophosphamide, and dexamethasone (dex) (VCD) is an effective regimen, commonly used in newly diagnosed MM (NDMM) (Leiba M et al, Br J Haematol 2014:166:702). Here, we report initial data from a Phase Ib study of ISA plus VCD (VCDI) in patients (pts) with NDMM (NCT02513186). Methods: This dose-escalation (DE) and expansion study enrolled pts with NDMM ineligible for transplantation. Treatment consisted of 2 phases: induction and maintenance. Induction (one 6-week cycle [cycle (C)1] followed by eleven 4-week cycles [C2-12]): ISA (10 or 20 mg/kg, sequentially enrolled) weekly during C1, then every 2 weeks; subcutaneous bortezomib (1.3 mg/m2) on Days (D)1, 4, 8, 11, 22, 25, 29, and 32 (C1), then weekly (C2-12); cyclophosphamide (300 mg/m2) weekly (C1) then on D1, 8, and 15 (C2-C12); dex (20 mg) on D1, 4, 8, 11, 15, 22, 25, 29, and 32 (C1) then D1, 2, 8, 9, 15, 16, 22, and 23 (aged Results: Enrolment is now complete; 17 pts were treated with VCDI. During the DE phase, 4 pts were treated at 10 mg/kg and 4 pts at 20 mg/kg. Based on initial safety (no DLTs occurred at either dose; MTD was not reached) and pharmacokinetic (PK) data, ISA 10 mg/kg was chosen as the recommended dose for the expansion cohort and 9 additional pts were treated at this dose (total 13 pts at 10 mg/kg). Median age was 71 (68-80) years. At baseline, 1, 1, and 15 pts were ISS Stage I, II, and III, respectively. At data cut-off (Dec 31, 2016), pts across both doses had been treated for a median of 3.0 (0.5-14.0) months (mo). Two pts discontinued treatment due to an adverse event (AE) (10 mg/kg: Grade [Gr] 3 bronchospasm and Gr 3 infusion-associated reaction [IAR]; 20 mg/kg: sudden death [during C1, not treatment related]) and 1 pt (10 mg/kg) discontinued due to disease progression. ISA dose omission was required in 5/13 (38%) pts at 10 mg/kg (Gr 2 bronchitis, Gr 2 mesenteric vein thrombosis, Gr 3 respiratory tract infection, Gr 3 hypertension, Gr 3/4 neutropenia) and none at 20 mg/kg. Dose omission of bortezomib, cyclophosphamide, and dex was required in 7, 5, and 8 pts, respectively. All pts experienced ≥1 AE. Most frequent AEs across both doses (any Gr; excluding laboratory abnormalities): IARs, 8 pts (47%); back pain, 7 pts (41%); nausea, 5 pts (29%); bronchitis, 5 pts (29%); peripheral neuropathy, hypertension, diarrhea, constipation, peripheral edema, and rash, 4 pts each (24%). Gr ≥3 AEs were reported in 11 (65%) pts and serious AEs (SAEs) in 4 (24%) pts (Gr 3 bronchospasm, Gr 2 mesenteric vein thrombosis, Gr 3 dorsal pain, Gr 5 sudden death). Except Gr 3 bronchospasm, no SAEs were treatment related. Nine IARs occurred in 8 pts, all in the first infusion. IARs were Gr 1/2 in all but 1 pt (Gr 3 bronchospasm). Gr 3/4 hematologic abnormalities (laboratory assessment): lymphopenia (8/16 evaluable pts), leukopenia (3/16), neutropenia (3/16), thrombocytopenia (1/16), anemia (1/16). From 15 efficacy-evaluable pts the ORR was 87% (13/15), including 2 stringent CRs, 3 CRs, 4 very good partial responses (VGPRs), and 4 partial responses. Two pts achieved a best response of stable disease, lasting 5 and 12 cycles, respectively. Median time to first response was 1.5 mo. Median duration of response in the DE phase was 11.1 mo, and 14 (82.4%) pts are continuing on treatment. ISA PK appeared unaffected by co-administration with VCD. Conclusions: These data suggest that VCDI is generally well tolerated with many pts demonstrating at least VGPR. Safety and efficacy data (including minimal residual disease status) with longer-term follow-up will be presented at the meeting. Funding: Sanofi Disclosures Ocio: Novartis: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; AbbVie: Consultancy; Pharmamar: Consultancy; Seattle Genetics: Consultancy; Array Pharmaceuticals: Research Funding; Mundipharma: Research Funding; Celgene: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Sanofi: Research Funding; BMS: Honoraria; Janssen: Honoraria. Bringhen: JJ: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria; BMS: Honoraria. Oliva: Celgene: Honoraria; Takeda: Honoraria. Rodriguez-Otero: BMS: Consultancy, Research Funding, Speakers Bureau; Celgene: Consultancy, Research Funding, Speakers Bureau; Janssen: Consultancy, Research Funding, Speakers Bureau. Kanagavel: Sanofi: Employment. Oprea: Sanofi RD Sanofi: Other: Stock holder. Wei: Sanofi RD Celgene: Honoraria, Research Funding; BMS: Honoraria, Research Funding; Janssen: Honoraria.

Inflammatory Bowel Disease and Thrombosis: A National Inpatient Sample (NIS) Study

Background: Inflammatory bowel disease (IBD) is a chronic inflammatory disease of the gastrointestinal mucosa, including two disorders, regional enteritis and ulcerative colitis. These disorders are characterized by defective immune regulation, in which T cells in the gastrointestinal mucosa secrete inflammatory cytokines and an inflammatory response that increases venous thromboembolism (VTE) risk, 2-3 times greater than in the general population. The mechanism by which thrombosis occurs and how to identify those at risk remain unclear.Methods: We conducted a cross-sectional analysis of discharge data from the National Inpatient Sample (NIS) between January 1, 2009 and December 31, 2014. The NIS is an all-payer database that approximates a 20% stratified sample of discharges from U.S. hospitals participating in the Healthcare Cost and Utilization Project. Discharges among individuals with and without IBD were evaluated by age, race, gender, primary and secondary diagnoses, demographics, and length of stay. De-identified discharge data were classified by the International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes for thrombosis, including deep venous thrombosis (DVT), pulmonary embolism (PE); arterial thrombosis and arterial embolism; intra-abdominal thromboses, including portal vein thrombosis, splenic/other vein thrombosis, and mesenteric vein thrombosis; and other thrombosis, including cerebral artery embolism/ thrombosis, intracranial venous sinus thrombosis, retinal vein occlusion; and hepatic vein thrombosis. Discharge-level weights from the NIS database were used to produce estimates representative of all community hospitals in the U.S. Thrombosis prevalence was compared between patients with and without IBD, as were demographics (age, race, gender), length of stay, inpatient mortality, and risk factors for thrombosis (dehydration, malnutrition, ports/catheters, chronic steroid use, malignancy, surgery, trauma, and immobilization). Medical conditions i.e. hypertension, renal failure. Continuous data (e.g. age) were compared by weighted simple linear regression. Categorical data (e.g. gender and risk factors) were compared across groups by the Rao-Scott Χ2 test. Weighted multivariable logistic regression models for thrombosis were fitted to estimate odds ratios and 95% confidence intervals.Results: During the 5-year period 2009-2014, the prevalence of thrombosis in patients with IBD (unweighted N= 374,315) was 7.5%, significantly higher than in non-IBD patients (unweighted N=44,748,771), 4.5%, p<0.001. Individuals with IBD and thrombosis were older than IBD without thrombosis, 57.5 years vs. 50.4 years, p<0.001. The most common types of thrombosis were mesenteric vein thrombosis, 7.4%, PE, 6.5%, DVT 6.2%, and portal vein thrombosis, 2.5%. The most common risk factors for thrombosis included surgery, 53.7%, ports/catheters, 13.2%, malignancy, 13.1%, dehydration, 12.4%, malnutrition, 8.9%, and chronic steroid use, 8.2%, which, except dehydration, were all more common than in IBD without thrombosis, p<0.001. Hypertension, 45.2%, hyperlipidemia, 21.5%, cardiac disease, 16.6%, diabetes, 14.9% and renal failure, 13.6%, each p<0.001, were also more common in those with thrombosis. Severity of illness was higher, 1.42 vs. 0.96, length of stay longer, 7.7 vs.5.5 days, and inpatient mortality higher, 3.8% vs. 1.5%, each p<0.001. After adjusting for age and comorbidity index, risk factors remaining significant for thrombosis included port/catheters, OR=1.73 (CI 1.66,1.81), chronic steroids, OR=1.61 (1.54,1.69), malnutrition, OR=1.34 (1.28,1.41), and malignancy, OR=1.13 (1.08,1.18), each p<0.001, while dehydration, OR=0.86 (0.83,0.90), and Asian race, OR=0.61 (0.52,0.72), each p<0,001, appeared protective against thrombosis.Conclusion: This NIS analysis indicates the prevalence of thrombosis in IBD is 1.7-fold greater than in those without IBD. Even after adjusting for age and severity of illness, the odds of thrombosis in IBD are 73% higher with ports, 61% higher with chronic steroids, 34% higher with malnutrition, and 13% higher with malignancy. These findings suggest the importance of anticoagulation, particularly in IBD patients admitted with ports/catheters, steroids, malnutrition, and/or malignancy and suggest potential benefit if continued long-term in the outpatient setting. DisclosuresRagni:Shire: Consultancy, Honoraria, Research Funding; Sangamo: Research Funding; Alnylam: Consultancy, Honoraria, Research Funding; MOGAM: Consultancy, Honoraria; Bayer: Consultancy, Honoraria, Research Funding; SPARK: Research Funding; NovoNordisk: Honoraria; Bioverativ: Consultancy, Honoraria, Research Funding; Biomarin: Consultancy, Honoraria, Research Funding; Genentech/Roche: Research Funding.

Protein C Infusion Therapy in an Adult Case of Severe Congenital Protein C Deficiency

Background: Severe congenital protein C deficiency (SCPCD) is a rare inherited disorder characterized by recurrent thrombosis, disseminated intravascular coagulation, and purpura fulminans. Due to limitations in traditional therapeutic options (anticoagulation, FFP, PCC), plasma-derived protein C concentrates have been used for both prophylactic and therapeutic indications. However, there are few reports of protein C infusion therapy in adults, with limited understanding of pharmacokinetics and no dosing guidelines available. We report the use of protein C concentrate in an individualized dose-finding study, in an adult patient in preparation for renal transplantation.Case: A 35 year old female (68 kg) with SCPCD (baseline PC activity < 0.10 U/mL) with an extensive personal and family history of thrombosis was to undergo renal transplant. Her thrombotic history included DVT and PE (age 4), recurrent DVT with PE (age 6), mesenteric vein thrombosis (age 6), arterial thrombosis in bowel (age 10), DVT (age 10), extensive superficial venous thrombosis (age 27), pregnancy-associated DVT (age 32), and internal jugular vein thrombosis (age 34), for which she was on long-term therapeutic Enoxaparin. She developed end-stage renal disease in March 2015 (age 33) in the setting of pregnancy-associated HELLP syndrome, and is currently awaiting a deceased donor renal transplant. In anticipation of her upcoming transplant, an intravenous protein C infusion trial was performed to establish a perioperative management plan.Results: The patient was admitted to hospital for this dose-finding study. She was administered Ceprotin® (human plasma-derived, virally-inactivated protein C concentrate) with an initial intravenous bolus (59 IU/kg) followed by an infusion (5 IU/kg/hr) to maintain a target PC level of 0.65-1.30 U/mL (see Table). Protein C activity was measured every 6 hours, and target levels were achieved over the 30-hour duration of the trial. The patient experienced no adverse events during the infusion trial.Conclusion: In this case report, target protein C levels were maintained using bolus and continuous infusion rates of protein C concentrate that were approximately half of those recommended by the manufacturer. This personalized trial, while resource-intensive, provided a feasible and safe method of preparing for a high-risk surgical procedure that could be adapted to other similar clinical situations. [Display omitted] DisclosuresCrowther:Leo Pharma: Research Funding; Shinogi: Consultancy; Boehringer Ingelheim: Speakers Bureau; Bayer: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Alexion: Speakers Bureau; Pfizer: Honoraria; Portola: Consultancy.

Splanchnic Vein Thrombosis Treatment with Rivaroxaban - a Case Series from the Prospective Dresden Noac Registry (NCT01588119)

Background : Although rivaroxaban is not specifically approved to be used in patients with splanchnic vein thrombosis (SVT), it may offer advantages due the oral intake and the specific pharmacological profile. As a consequence, off-label use of rivaroxaban in single cases has been reported. However, the effectiveness and safety of rivaroxaban in SVT remains to be established.Patients and methods : Using data from the prospective, non-interventional multicentric Dresden NOAC we evaluated a subgroup of patients receiving rivaroxaban for acute or chronic SVT treatment. All patients in the registry undergo long-term follow-up by quarterly phone calls and suspected thromboembolic and bleeding outcome events are centrally adjudicated using standard definitions.Results: Until June 30th 2017, 23 patients receiving rivaroxaban for SVT treatment were enrolled (65% male, median age 56 years). In these, SVT manifested as portal vein thrombosis in 15 cases (65.2%), mesenteric vein thrombosis in 2 (8.7%) and in both localizations in 6 (26.1%) cases. Idiopathic SVT was diagnosed in 78% of cases; 13% had intra- abdominal infections and 9% had cancer (table 1).Median time between diagnosis and initiation of rivaroxaban was 32 days (25th/75th percentile 11.5-125.5 days). Mean exposure time of rivaroxaban was 13 months (range 1-43 months), during which no thromboembolic event occurred. Ten patients had a total of 19 bleeding complications during treatment with rivaroxaban, which (according to International Society of Thrombosis and Haemostasis definition) were minor bleeding in 8 cases, clinically relevant non-major bleeding in 6 and major bleeding in 5 cases (3 x gastrointestinal, 1 x hemorrhoid; 1 x traumatic intracranial bleeding).During follow-up (mean 23 months; range 1-59 months), 7 patients had a scheduled end of rivaroxaban treatment, 2 patients were electively switched to prophylactic dosages of apixaban for long-term secondary prevention and 5 patients had unplanned permanent discontinuation of oral anticoagulation. Five patients died during follow-up (2x traumatic intracranial bleeding, 3 terminal malignant diseases).Detailed information on thrombus burden at baseline and during follow-up was available for 17/23 patients (table 2). Of these, 9 patients initiated rivaroxaban in the first 30 days after SVT diagnosis and demonstrated complete clot resolution in 8 and stable thrombus in 1 case. In contrast, those 8 patients who initiated rivaroxaban later than 30 days were found to have complete resolution or improvement in only two cases and stable thrombus burden without improvement in the remaining 6 cases.Conclusions: Our cohort of 23 consecutive patients currently represents the largest prospectively collected case series of rivaroxaban treatment for SVT. In this cohort treatment with rivaroxaban demonstrated high effectiveness to prevent thromboembolic complications but bleeding complications are common, which is known for SVT patients. Therefore, careful risk-benefit assessments are especially needed in this indication. Early initiation of rivaroxaban resulted in fast thrombus resolution in the majority of cases, whereas late initiation tended to achieve stable clot burden only. A fast SVT resolution with oral direct factor Xa inhibitors may be supported by their first-pass effect, which, compared to LMWH or VKA, should result in high drug concentrations at the site of thrombus in the splanchnic system. It remains to be seen if the fast clot resolution in early initiators of rivaroxaban will reduce late sequelae such as gastrointestinal bleeding from varicose veins, which is the most feared clinical consequence of residual clot in SVT. [Display omitted] DisclosuresMarten:Bayer HealthCare: Honoraria; Daiichi Sankyo: Honoraria. Beyer-Westendorf:Bayer: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding; Daiichi-Sankyo: Honoraria, Research Funding; Boehringer-Ingelheim: Honoraria, Research Funding.

Cancer-Associated Splanchnic Vein Thrombosis.

Splanchnic vein thrombosis (SVT), which includes portal, mesenteric, and splenic vein thrombosis and the Budd-Chiari syndrome, is an infrequent manifestation of venous thromboembolism (VTE). Like typical site VTE, SVT is also frequently associated with cancer, particularly intra-abdominal solid malignancies and myeloproliferative neoplasms (MPNs). The clinical presentation of SVT is nonspecific. Symptoms may be related to the underlying malignancy, and thrombosis is incidentally diagnosed by imaging studies for cancer staging or follow-up in a substantial proportion of cases. The occurrence of SVT predicts worse prognosis in patients with liver or pancreatic cancer and, not uncommonly, SVT may precede the diagnosis of cancer. Therefore, the occurrence of an apparently unprovoked SVT should prompt careful patient evaluation for the presence of an underlying malignancy or MPN. Cancer patients carry a high risk of VTE extension and recurrence and long-term anticoagulant treatment is suggested in the absence of high risk of bleeding. Either LMWH or direct oral anticoagulants (DOACs) are suggested for the treatment of patients with cancer-related SVT, although limited experience is available on the use of DOACs in these settings. Vitamin K antagonists (VKAs) are suggested for the short and long-term treatment of SVT associated with MPN. This review outlines the epidemiological aspects, pathogenesis, risk factors, and diagnosis of cancer-associated SVT, and addresses questions regarding the management of this challenging condition.

Superior mesenteric vein thrombosis in a pregnant woman: Diagnostic and management challenge.

Superior mesenteric vein thrombosis in a pregnant woman: Diagnostic and management challenge.

Primary antiphospholipid antibody syndrome presenting as acute superior mesenteric vein thrombosis

Antiphospholipid antibody syndrome (APS) is an autoantibody mediated thrombophilia characterised by recurrent arterial or venous thrombosis and/or pregnancy morbidity. APS presenting as thrombosis in mesenteric venous system is relatively uncommon (10%). Here, we present a case of primary APS presenting as acute superior mesenteric vein (SMV) thrombosis in a 38-year-old female. She was admitted with the complaints of abdominal pain and constipation for five days. Her abdomen was distended with sluggish bowel sounds. Her abdominal contrast enhanced computed tomography revealed thrombosis of SMV, splenic vein and portal vein. She was initially kept on conservative management and started on anticoagulants. Her coagulation work-up revealed that she was positive for anticardiolipin antibody and therefore, the diagnosis of APS was made. She was continued on conservative management and anticoagulants. On the tenth day of admission, after starting oral diet, she developed severe abdominal pain and abdominal signs of peritonitis. She was then taken up for emergency laparotomy. Intraoperatively; there was 100 cm of gangrenous ileal segment, about 60 cm from ileocecal junction and 160 cm from duodenojejunal flexure. The gangrenous ileal segment was resected and a double barrel ileostomy was constructed. She had an uneventful postoperative recovery and was started on lifelong anticoagulants.

Portomesenteric venous thrombosis in a postmenopausal female with testosterone implant: a case report

BackgroundAcute portal vein thrombosis is a rare medical event usually seen in liver disease, but it can also occur due to any inherited or acquired procoagulable state that triggers venous occlusion. Hormonal therapies have been associated with an increased risk of prothrombotic states. This case report documents a portomesenteric venous thrombosis in a postmenopausal woman with testosterone implant for the treatment of hypoactive sexual desire and discusses the importance of identifying hypercoagulable risk factors before initiating hormone replacement therapy. We want to improve the awareness of an unusual medical complication associated with hormone replacement therapy and shed light on how testosterone implants could facilitate a thrombotic event related to other risk factors such as obesity and chronic hypoxic states, as well as the importance of differential diagnosis in the evaluation of postmenopausal women on testosterone replacement therapy presenting with acute abdominal pain.Case presentationA 55-year-old obese postmenopausal Hispanic female with medical history of chronic obstructive pulmonary disease presents with intractable abdominal pain, is found to have elevated hemoglobin and hematocrit, and an abdominopelvic computed tomography scan revealing portal and superior mesenteric vein thrombosis. Further evaluation excluded inherited and acquired thrombophilia but revealed elevated testosterone levels. The patient was treated with anticoagulation, which resulted in recanalization of the portal and superior mesenteric veins.ConclusionSupraphysiologic levels of testosterone caused by testosterone implants as a treatment of hypoactive sexual desire in postmenopausal women can contribute to thrombotic events in the presence of additional prothrombotic risk factors. Therefore, testosterone therapy should include a thorough risk assessment for prothrombotic states, be tailored to patients’ physiologic testosterone levels, and have close follow-up with testosterone level monitoring.

Mesenteric ischemia in a patient with COVID 19 infection

The novel COVID-19 disease, caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus, apart from its respiratory complications and coagulopathy, is also involved in damage to other organ systems. We present a report of presumptive case of COVID-19 positive patient with no respiratory symptoms with superior mesenteric vein and portal vein thrombosis along with acute intestinal ischemia. The patient underwent exploratory laparotomy, resection of the ischemic bowel loops with proximal ileostomy and distal mucous fistula. The case highlights that despite the absence of respiratory symptoms, patients infected with SARS-CoV-2 may show atypical presentations, such as gastrointestinal symptoms.

Anticoagulation and Transjugular Intrahepatic Portosystemic Shunt for the Management of Portal Vein Thrombosis in Cirrhosis: A Prospective Observational Study.

Current guidelines recommend anticoagulation as the mainstay of portal vein thrombosis (PVT) treatment in cirrhosis. However, because of the heterogeneity of PVT, anticoagulation alone does not always achieve satisfactory results. This study aimed to prospectively evaluate an individualized management algorithm using a wait-and-see strategy (i.e., no treatment), anticoagulation, and transjugular intrahepatic portosystemic shunt (TIPS) to treat PVT in cirrhosis. Between February 2014 and June 2018, 396 consecutive patients with cirrhosis with nonmalignant PVT were prospectively included in a tertiary care center, of which 48 patients (12.1%) were untreated, 63 patients (15.9%) underwent anticoagulation, 88 patients (22.2%) underwent TIPS, and 197 patients (49.8%) received TIPS plus post-TIPS anticoagulation. The decision of treatment option mainly depends on the stage of liver disease (symptomatic portal hypertension or not) and degree and extension of thrombus. During a median 31.7 months of follow-up period, 312 patients (81.3%) achieved partial (n = 25) or complete (n = 287) recanalization, with 9 (3.1%) having rethrombosis, 64 patients (16.2%) developed major bleeding (anticoagulation-related bleeding in 7 [1.8%]), 88 patients (22.2%) developed overt hepatic encephalopathy, and 100 patients (25.3%) died. In multivariate competing risk regression models, TIPS and anticoagulation were associated with a higher probability of recanalization. Long-term anticoagulation using enoxaparin or rivaroxaban rather than warfarin was associated with a decreased risk of rethrombosis and an improved survival, without increasing the risk of bleeding. However, the presence of complete superior mesenteric vein thrombosis was associated with a lower recanalization rate, increased risk of major bleeding, and poor prognosis. In patients with cirrhosis with PVT, the individualized treatment algorithm achieves a high-probability recanalization, with low rates of portal hypertensive complications and adverse events.

Portal vein thrombosis in patients with hepatosplenic schistosomiasis who underwent oesophagogastric devascularization combined with splenectomy.

Portal vein thrombosis (PVT) has been described in nearly 50% of patients who underwent oesophagogastric devascularization combined with splenectomy (EGDS), but no previous study has compared its occurrence in surgical and non-surgical groups. This study aimed to investigate PVT in hepatosplenic schistosomiasis (HSS) and its association with EGDS and upper variceal bleeding (UVB). Retrospectively, 104 HSS individuals were enrolled. Following EGDS, the occurrence of PVT, mesenteric vein thrombosis (MVT), hospital admissions and UVB were recorded. EGDS was performed in 27 (26%) patients. PVT and MVT were detected in 30 (33%) and 8 (9.8%) patients, respectively. Patients who underwent EGDS were at greater risk of PVT (63% vs 19.7%; odds ratio [OR] 6.12 [95% confidence interval {CI} 2.3 to 16.1], p<0.001) when compared with a non-surgical approach. There was no significant difference in UVB occurrence and β-blocker usage. PVT was associated with more hospital admissions (p=0.030) and higher alkaline phosphatase levels (p=0.008). UVB occurrence in patients with and without thrombosis was similar. In multivariate analysis, after adjustment, PVT was associated with the surgical approach (OR 4.56 [95% CI 1.55 to 13.38], p=0.006) and age at HSS diagnosis (OR 0.94 [95% CI 0.90 to 0.99], p=0.021). EGDS was not associated with a decreased frequency of UVB when compared with the non-surgical approach but was an independent risk factor for PVT.

Hypereosinophilic Syndrome (HES) Presenting as Coagulopathy

While coagulopathy is not typically associated with hypereosinophilic syndromes (HES), this can be a manifestation. Here we present a case of HES initially presenting with mesenteric vein thrombosis with ischemic colitis resulting in hemicolectomy who was ultimately found to have HES.

A Case of Portal Vein/Superior Mesenteric Vein Thrombosis with Widespread Small Bowel Necrosis Possibly Caused by Oral Administration of Eltrombopag

A Case of Portal Vein/Superior Mesenteric Vein Thrombosis with Widespread Small Bowel Necrosis Possibly Caused by Oral Administration of Eltrombopag

Mesenteric Vein Thrombosis with Multiple Etiologies- A Rare Cause of Abdominal Pain During COVID Times

Mesenteric Vein Thrombosis with Multiple Etiologies- A Rare Cause of Abdominal Pain During COVID Times