Mesenteric Vein Thrombosis Research Articles

Successful Treatment of Acute Superior Mesenteric Vein Thrombosis Caused by Infection Using the Ileocolic Vein as an Approach Site for Thrombectomy

Successful Treatment of Acute Superior Mesenteric Vein Thrombosis Caused by Infection Using the Ileocolic Vein as an Approach Site for Thrombectomy

Incidence of Silent Thrombosis in Myeloproliferative Neoplasm Patients below 60 Years : Single Center Egyptian Study

Background: Identification of JAK-2 mutation even in absence of myeloproliferative disorders was found to be related to venous thromboembolism occurrence. The aim of this work is to screen myeloproliferative neoplasm ( MPN) patients for venous thrombosis and study its correlation with both JAK 2 allele burden and with symptoms the patients presented with. Methods: We enrolled 73 cases with JAK2 positive MPN in the period between August 2015 till Feb 2017. All patients were screened for thrombosis in venous system in neck, upper and lower limbs, superior and inferior Venae Cavae and portal and mesenteric venous systems system using color Doppler Ultrasound. Results: 53 patients (72.6%) were below 60 years. Forty even (64.4%) were females and 26(35%) were males. Twenty two (30%) of cases were Essential Thrombocytosis (ET), 35(248%) were Polycythemia Vera (PV) and 16 (22%) were Myelofibrosis (MF). Twenty seven venous thrombotic attacks were reported in twenty two patients (30.1%). Seventeen patients (23%) had mesenteric and portal vein thrombosis,six patients had iliofemoral (8%) and 4 (5%) had combined lower limb and portal thrombosis. Eight patients (10.8%) had active thrombosis at screening. Only three (4%) patient were symptomatising with pain during screening. Sixteen patients with thrombosis were below 60 (30% of those below 60 years) and 6 were above sixty years (also 30% of those above sixty years). Correlation analysis between JAK2 allele burden and thrombosis was not statistically significant (r=0.3 ,p value=0.5). However, JAK 2 allele burden was statistically higher in those above sixty years in both thrombosed and non-thrombosed cases in comparison to those below sixty years (p= 0.03, 0.017 respectively). The incidence of pruritis (p =0.02) and of abdominal pain (p=0.039) was significantly different between thrombosed and non-thrombosed cases. Comparison of 8 cases with active thrombosis to old thrombosis revealed no statistical difference in the MPN10 score (p>0.05). Conclusion: We recommend routine screen for venous thrombosis in any case of MPNs once diagnosed and screening for MPNs in any case with venous thrombosis . Further research in MPN group age below 60 years of age is highly recommended. DisclosuresNo relevant conflicts of interest to declare.

Venous thrombosis in unusual sites: A practical review for the hematologist.

Thrombosis of unusual venous sites encompasses a large part of consultative hematology and is encountered routinely by practicing hematologists. Contrary to the more commonly encountered lower extremity venous thrombosis and common cardiovascular disorders, the various thromboses outlined in this review have unique presentations, pathophysiology, workup, and treatments that all hematologists should be aware of. This review attempts to outline the most up to date literature on cerebral, retinal, upper extremity, hepatic, portal, splenic, mesenteric, and renal vein thrombosis, focusing on the incidence, pathophysiology, provoking factors, and current recommended treatments for each type of unusual thrombosis to provide a useful and practical review for the hematologist.

Recurrent Primitive Neuroectodermal Tumor (PNET) of the Pancreas

Ewing's family of tumors (EFT) originate from neuronal crest cells and share morphological, histological and cytogenic features. EFTs include typical (osseous) Ewing's sarcoma, atypical (non-osseous) Ewing's sarcoma, primitive neuroectodermal tumor (PNET), and Askin tumor. Only a few cases of ES/PNETs of the pancreas have been reported and even fewer cases of recurrent pancreatic PNETs are known. Herein we report a case of recurrent pancreatic PNET presenting as abdominal pain ten years following treatment of left scapular Ewing's sarcoma. Four years following partial resection, local radiation and CHOP chemotherapy for left scapular Ewing's sarcoma, a 54-year-old male presented with epigastric abdominal pain. CT scan of the abdomen demonstrated a mass at the head of the pancreas and biopsy confirmed a CD-99 positive round blue cell tumor. FISH showed 15 % ESWR1 locus rearrangement. Together these findings were consistent with pancreatic PNET. The patient was treated with local radiation and CHOP chemotherapy. Treatment response was monitored with serial PET scans. Unfortunately, after six years of sustained response the patient presented with epigastric abdominal pain. Laboratory studies were significant for elevated bilirubin (1.1 mg/dL). A mesenteric vein thrombosis was detected on CT scan as well as a 43 mm by 29 mm mass at the pancreatic head. PET scan confirmed a 19 mm by 22 mm FDG avid area at the head of the pancreas. Biopsy demonstrated a CD-99 positive round blue cell tumor. Overall the findings were consistent with recurrent pancreatic PNET.EFT/PNETs are round blue cell tumors with neuroendocrine differentiation (chromogranin A, synaptophysin or neuron specific enolase) and CD-99 expression. Although, CD-99 is nonspecific. Additionally, many EFTs demonstrate t(11; 12) (q24; q12) chromosomal translocation resulting in the fusion protein EWS-FLI1 which disrupts transcription and drives tumor growth. EFTs commonly arise from long bones and afflict young patients. Although rare, EFT/PNETs can arise from solid organs. Primary PNETs of the lung, urinary bladder, gall bladder, and uterus have been reported. Only 0.3 % of pancreatic masses are diagnosed as EFT/PNET. Our case highlights the importance of correlating clinical, radiographic, and pathological findings in the diagnosis of pancreatic PNET and emphasizes the importance of multimodality treatment of this aggressive disease.

Lupus Enteritis as the Only Manifestation of Active Systemic Lupus Erythematosus

Lupus enteritis is a rare manifestation of systemic lupus erythematosus (SLE). It is a difficult diagnosis to make, especially in the absence of other symptoms related to active SLE. We present a case of a 25 year old female who presented with lupus enteritis as the sole manifestation of active SLE. A 25 year old female presented to the ED with diffuse abdominal pain, diarrhea, nausea, and vomiting for 2 days. She had a medical history of seasonal allergies. Family history was significant for SLE in her cousin. Her vital signs were normal, and physical exam revealed lower abdominal tenderness. A CT of the abdomen showed marked circumferential wall thickening and edema of the proximal and mid small bowel loops predominantly involving the submucosa (Image 1). Our main differential diagnoses were intestinal angioedema and mesenteric vein thrombosis. The mesenteric vessels were patent and without evidence of thrombosis. Infectious workup was negative. Laboratory testing for hereditary angioedema showed a normal C1 Esterase Inhibitor level and low C3 and C4 levels. Autoimmune work-up showed elevated ANA (13.6), anti-Smith antibody (ab), and anti-RNP ab (Table 1). The patient was diagnosed with SLE enteritis. She was maintained on bowel rest, given intravenous (IV) hydration, and started on methylprednisolone 60 mg IV daily. She had significant improvement of all her symptoms and was discharged on prednisone 75 mg by mouth daily. In SLE, isolated gastrointestinal activity without other organ involvement is highly unusual. Lupus enteritis presents with non-specific symptoms, making the diagnosis difficult. Nevertheless, it is important to identify this disease manifestation as the mortality among patients with SLE with acute abdominal pain is approximately 11%. Lupus enteritis causes submucosal edema of the jejunum and ileum. The classic findings on CT scan include circumferential bowel wall thickening (“target sign”), dilation of intestinal segments, and engorgement of mesenteric vessels (“comb sign”). The CT scan in our case showed the “target sign”. Given her negative work up for hereditary angioedema and her family history of lupus, we decided to test for SLE. We did not perform an upper endoscopy because it often does not contribute to diagnosis. It's important to note that while most sources advocate pulse dose steroids, we were able to achieve symptomatic control with methylprednisolone 60 mg daily.2543_A Figure 1. Ab (antibody); ANA (anti-nuclear antibodies); dsDNA (double-stranded DNA); Anti-RNP (anti-ribonucleoprotein).2543_B Figure 2. Image 1. Marked circumferential wall thickening consistent with “target sign” involving multiple loops of proximal/mid small bowel. There is predominantly submucosal thickening/edema, more predominantly in the mid abdomen. The thickened small bowel loops are minimally dilated. However, there is no transition point. There is moderate volume of ascites.

Hyperhomocysteinemia with Simultaneous Superior Mesenteric, Portal and Splenic Vein Thrombosis in a Young Adult

Hyperhomocysteinemia with Simultaneous Superior Mesenteric, Portal and Splenic Vein Thrombosis in a Young Adult

Thrombosis of atypical location: how to treat patients in the era of direct oral anticoagulants?

In 4% of cases, venous thromboembolism (VTE) involves organ‑related venous territories such as splanchnic, renal, gonadal, and cerebral venous segments, and is often called venous thromboembolism of atypical location (VTE‑AL). Recommendations regarding the method, intensity, and duration of anticoagulant therapy for VTE‑AL are not well established. Direct oral anticoagulants (DOACs) have been a promising alternative to vitamin K antagonists in the treatment of acute VTE. However, all major clinical trials on DOACs excluded patients with VTE‑AL. Therefore, data on the use of DOACs in patients with VTE‑AL are still limited to case reports and small clinical series, with a relative predominance of publications on splanchnic vein thrombosis including mesenteric, splenic, portal, and hepatic vein thrombosis. The only randomized clinical trial comparing a clinical outcome of patients with acute portal vein thrombosis randomized to either rivaroxaban or warfarin treatment yielded significantly impaired results due to the use of an atypical rivaroxaban dose. A prospective registration of clinical outcome for DOACs used in patients with VTE‑AL, in those with VTE of typical location, and in those with VTE‑AL treated with enoxaparin showed similar VTE recurrence and major bleeding rates in all 3 groups. High cancer prevalence, typical for VTE‑AL, significantly impacted survival as well as VTE recurrence rates and major bleeding outcomes in this study. In general, although still limited, the results for DOAC use in VTE‑AL are encouraging and we do not hesitate to use DOACs, particularly rivaroxaban or apixaban, in selected patients with VTE‑AL.

Acute Superior Mesenteric Vein Thrombosis With Small Intestinal Ischemia

Acute superior mesenteric vein thrombosis results in sudden interruption of blood supply to a segment of small intestine leading to ischemia followed by intestinal infarction and necrosis of that segment. Immediate systemic anticoagulation and early surgical intervention are required to remove the infracted segment of bowel to prevent sepsis and death. The mesenteric ischemia due to thrombosis of superior mesenteric vein is a rare condition of the intestine, however intestinal infarction associated with it is even more uncommon. Systemic hypercoagulable state is usually present in most of these patients. I, report a case of 43 years old Caucasian male who presented to the emergency room with severe diffuse upper abdominal and back pains out of proportion of his abdominal findings associated with nausea and vomiting. Past history of deep vein thrombosis (DVT) of lower extremity in the patient and his sister was documented. Computed tomography of abdomen with intravenous contrast revealed superior mesenteric vein thrombosis and extension of thrombus into portal vein along with its segmental branches resulting in ischemia of distal small bowel. The patient was initially treated with systemic anticoagulation but due to lack of response to conservative management for 12 h the patient was taken to operating room and underwent resection of about 2 feet of ischemic distal small bowel with good post operative recovery. Acute superior mesenteric vein thrombosis associated with mesenteric ischemia requires prompt diagnosis, urgent medical and early surgical intervention to prevent sepsis, high morbidity and mortality. J Med Cases. 2018;9(9):293-295 doi: https://doi.org/10.14740/jmc3118w

Rectal varices due to chronic inferior mesenteric vein thrombosis caused by external compression in a large hiatus hernia containing the pancreas

A 79-year-old woman presented with a large fresh rectal bleed. Computed tomography revealed that she had a large type IV hiatus hernia, which contained the stomach and pancreas. Compression of the inferior mesenteric vein and splenic vein had led to thrombosis within these vessels and retrograde flow within the inferior mesenteric vein. This had led to the formation of portosystemic rectal varices. Ectopic varices occasionally form in the rectum, often in the context of liver cirrhosis. At the time of writing, ours is the first reported case of portosystemic rectal varices formulated in response to obstruction of vessels within a hiatus hernia.

Congenital Thrombophilia in Patients With Superior Mesenteric Venous Thrombosis or Portal Vein Thrombosis.

We explored the relationship between abdominal vein thromboses, including portal vein thrombosis (PVT) and superior mesenteric vein thrombosis (SMVT), and thrombophilia. The frequency of thrombophilia, such as antithrombin (AT), protein C (PC), or protein S (PS) gene mutations, was examined in 21 patients with PVT, 6 patients with SMVT, and 6 patients with both PVT and SMVT. Low levels of AT, PC, or PS were frequently detected in patients with PVT or mesenteric vein thrombosis, and 4 mutations in the PS gene, 3 mutations in the PC gene, and 2 mutations in AT the gene were detected. Protein S Tokushima was detected in 3 of 4 patients with a PS gene mutation and was associated with 2 other PS gene mutations. The onset of PVT or SMVT was almost idiopathic in patients with congenital thrombophilia. Both PVT and SMVT were frequently caused by an AT, a PC, or a PS mutation, and the onset of these thromboses due to thrombophilia was frequently idiopathic.

3:09 PM Abstract No. 362 Percutaneous transhepatic catheter-directed thrombolysis for the treatment of acute portal and mesenteric vein thrombosis

To evaluate our institutional outcomes following catheter-directed thrombolysis (CDT) for the treatment of acute portal and mesenteric vein thrombosis (PVT). A retrospective chart review of all patients with PVT treated with CDT over a ten-year period was performed. Thrombus was quantified using the Yerdel Classification pre- and post-thrombolysis. Demographics, risk factors for PVT, symptoms, clinical and technical success rates, and complications were analyzed. Subgroup analyses were performed comparing cirrhotic and non-cirrhotic patients. Twenty-eight patients (mean age 50.6 years) were treated with CDT, including 8 cirrhotic patients. Major risk factors included recent surgery, cirrhosis, and malignancy. Presenting symptoms were abdominal pain and nausea. Immediate clinical and technical success rates were 82.1% and 89.3%, respectively. Median Yerdel score significantly decreased in all groups, but more dramatically in the non-cirrhotic population (3.5 vs. 1, p = 0.034). Pain significantly decreased from a median score of 7 (IQR 4-9.5) pretreatment to 0 (IQR 0-3.25) posttreatment. Two procedure related patient deaths occurred, 1 bleed in a heparinized patient (aPTT >200) 5 days postprocedure, and multi-organ failure in a patient with a thrombosed SMV stent placed post Whipple. Additional complications included self-limited SMV extravasation post angioplasty, rapid ventricular response requiring antiarrhythmic medications, blood loss requiring transfusion, and vomiting requiring a nasogastric tube. There was a trend towards a lower complication rate in the cirrhotic population (25% vs. 55%). Nineteen patients had long-term follow-up (median 10.8 mo IQR: 4.9-18.7 mo) with 78.9% stable or decreased thrombus and 21.1% re-thrombosis. CDT for acute portal and mesenteric vein thrombosis has a good success rate with long-term partial and complete patency up to 79%, however continues to have a modest rate of significant complications. Given these findings, further investigation with a medically managed control group is warranted.

Computed tomography findings after radiofrequency ablation in locally advanced pancreatic cancer

PurposeThe purpose of the study was to provide a systematic evaluation of the computed tomography(CT) findings after radiofrequency ablation (RFA) in locally advanced pancreatic cancer(LAPC).MethodsEighteen patients with intra-operative RFA-treated LAPC were included in a prospective case series. All CT-scans performed prior to RFA and 1 week and 3 months of post-RFA, according to standard regimen, were assessed by two radiologists in consensus, using standardized radiological scoring lists.Results51 CT-scans were assessed. One week after RFA, the ablation zone was visible in all patients as a (partially) sharply defined (83%), heterogeneous area (94%). At 3 months of follow-up, the ablation zone was completely invaded by tumor in 67% of patients and still present, but decreased in 33%. In two patients (11%), local thrombosis and/or occlusion of the superior mesenteric vein occurred. The occlusions persisted without clinical consequences and the thrombosis disappeared. A peripancreatic fluid collection was visible 1 week after RFA in 3 patients, wherein the ablation zone extended ventrally outside of the pancreas.ConclusionsDirectly after RFA for LAPC, a well-defined ablation zone is visible on CT-imaging. This ablation zone is usually replaced by tumor ingrowth after 3 months. Moreover, the ablation zone regularly included vascular structures, with rare asymptomatic venous occlusion or thrombosis and without adverse effects on arteries.

Screening for Venous Thrombosis in Young Myeloproliferative Neoplasms and Impact of JAK 2 Allele Burden on Its Incidence: Egyptian Experience

Background: Identification of JAK-2 mutation even in absence of myeloproliferative disorders was found to be related to venous thromboembolism occurrence. The aim of this work is to screen MPN patients for venous thrombosis and study its correlation with both Jak 2 allele burden and with symptoms the patient presented with. Methods: We enrolled 73 cases with Jak2 positive MPN from our Hematology Clinic in the period between August 2015 till Feb 2017. All patients had been screened for thrombosis in venous system in both LLs, ULs, portal and mesenteric system using color Doppler US. Results: 53 patients (72.6%) were below 60 years. Twenty two (30%) of cases were ET, 35(248%) were PV and 16 (22%) were IMF. Twenty seven venous thrombotic attacks were reported in twenty two patients (30.1%). Seventeen patients (23%) had mesenteric and portal vein thrombosis. Six patients had iliofemoral (8%) and 4 (5%) had combined LL and portal thrombosis. Eight patients (10.8%) had active thrombosis at screening. Only three(4%) patient were symptomatizing with pain during screening. Puritis (p =0.02) and abdominal pain (p=0.039) were statistically significant different between thrombosed and non thrombosed cases. Comparison of 8 cases with active thrombosis to old ones revealed no statistical difference in the MPN10 (p>0.05). Conclusion: we recommend routine screen for venous thrombosis in any case of MPNs once diagnosed and screening for MPNs in any case with venous thrombosis especially with portal venous thrombosis. If MPN cases presented with increasing pruritus or abdominal pain should be also screened for venous thrombosis. Further research on large scale in MPN group age below 60 years regarding pathogenesis of thrombosis is highly recommended. Funding Statement: The research was self-funded. Declaration of Interests: The authors declare no conflict of interest. Ethics Approval Statement: This study was approved by the research ethical committee of kasr Al Aini faculty of Medicine- Cairo University-Egypt in 2015.

Mesenteric Vein Thrombosis after Laparoscopic Right Colectomy - A Case Report and Literature Review

Introduction: Mesenteric vein thrombosis (MVT) is a rare but serious condition. Prompt diagnosis and early treatment are essential to avoid high mortality from this condition. Very few cases of this complication after laparoscopic colon resection have been reported in the literature. Presentation of case: We report superior mesenteric vein thrombosis in a 69-year old male after uneventful laparoscopic right colectomy for colon cancer. Incidental diagnosis of MVT was made on staging CT scan of abdomen one month after surgery. He was promptly treated with anticoagulation which avoided adverse outcomes. The patient was asymptomatic throughout the course of the disease. Discussion: There is significant lack of its awareness about this disease in medical fraternity due to very low incidence. Additionally, signs and symptoms are often confusing especially in patients who have had recent surgery. Pain abdomen, nausea, and diarrhea are most common symptoms. High degree of clinical suspicion by treating physician is the key to early diagnosis. Undiagnosed patients have high mortality due to consequent mesenteric ischemia and sepsis. CT angiography is the most important diagnostic test and prompt systemic anticoagulation is the treatment of choice. Conclusion: Awareness of this condition and a high index of suspicion are two most important attributes in fighting with this deadly and rare complication after laparoscopic colon resection.

Elevated factor VIII and mesenteric vein thrombosis

Elevated concentrations of factor VIII have recently been associated with de novo development of deep vein thrombosisand its recurrence Occurrence of mesenteric vein thrombosis in patients with elevated factor VIII has been rarely described but not well characterized. We describe in this article a young patient who developed superior mesenteric vein thrombosis and on evaluation was found to have abnormally elevated factor VIII.

AngioJet-assisted transvenous-transhepatic mechanical thrombectomy in the portal vein.

PurposeTo evaluate AngioJet-assisted transvenous portal vein (PV) thrombectomy for non-cirrhotic patients with total portal vein and mesenteric vein thrombosis (PVMVT).Material and methodsFrom 2015 to 2016 four patients (3 male, mean 43.9 years, range 33-52 years) with acute (3 cases) and acute-on-chronic (1 case) PVMVT underwent transvenous thrombolysis. All patients received initial AngioJet (Boston Scientific, Natick, MA, USA) thrombectomy followed by continuous catheter directed thrombolysis with Urokinase (Medac, Wedel, Germany) for 22-52 hours. Transjugular intrahepatic portosystemic shunts (TIPS), using Viatorr stent grafts (W.L. Gore and Associates, AZ, USA; mean diameter: 10 mm, length: 60-80 mm), were implanted in all patients. Patients were followed clinically and with imaging (mean 646 days, range 392 to 936 days).ResultsTechnical success was 100%. Therapeutic success was achieved in 75% of cases. AngioJet-assisted thrombectomy substantially reduced thrombus load in the acute cases, while only slight improvement was achieved in the acute-on-chronic case. Continuous thrombolysis subtotally re-established PV flow in the acute cases, while only minimal improvement was seen in the acute-on-chronic case. Following TIPS implantation complete PV recanalisation could be achieved in all acute cases. In the acute-on-chronic case initial stagnant PV flow was seen; however, PV and TIPS re-occluded 10 days after implantation. During follow-up PV remained patent in acute cases.ConclusionsAngioJet-assisted thrombectomy was technically feasible and uncomplicated in all of our patients. The initial results suggest that AngioJet-assisted thrombectomy facilitates recanalisation in acute and severe cases of PVMVT.

T-PA power-pulse spray with rheolytic mechanical thrombectomy using cross-sectional image-guided portal vein access for single setting treatment of subacute superior mesenteric vein thrombosis.

Background:Isolated superior mesenteric vein (SMV) thrombosis is a rare but potentially fatal condition if untreated. Current treatments include transjugular or transhepatic approaches for rheolytic mechanical thrombectomy and subsequent infusions of thrombolytics. Tissue plasminogen activator (t-PA) power-pulse spray can provide benefit in a single setting without thrombolytic infusions. Computed tomography (CT) guidance for portal vein access is underutilized in this setting.Materials and Methods:Case 1 discusses acute SMV thrombosis treated with rheolytic mechanical thrombectomy alone using ultrasound guidance for portal vein access. Case 2 discusses subacute SMV thrombosis treated with the addition of t-PA power-pulse spray to the rheolytic mechanical thrombectomy, using CT guidance for portal vein access.Results:With rheolytic mechanical thrombectomy alone, the patient in Case 1 had significant improvement in abdominal pain. Follow-up CT demonstrated no residual SMV thrombosis and the patient continued to do well in long-term follow-up. With the addition of t-PA power-pulse spray to rheolytic mechanical thrombectomy, the patient in Case 2 with subacute SMV thrombosis dramatically improved postprocedure with resolution of abdominal pain. Follow-up imaging demonstrated patency to the SMV and partial resolution of thrombus. The patient continued to do well at 2-year follow-up.Conclusions:Adding t-PA power-pulse spray to rheolytic mechanical thrombectomy can provide benefit in a single setting versus mechanical thrombectomy alone and prevent the need for subsequent infusions of thrombolytic therapy. CT guidance is a useful alternative of localization for portal vein access via the transhepatic route that is nonoperator-dependent and helpful in the case of obese patients.

A Case of Small Intestine Necrosis by Superior Mesenteric Vein Thrombosis Due to Portal Hypertension

A Case of Small Intestine Necrosis by Superior Mesenteric Vein Thrombosis Due to Portal Hypertension

A Case of Superior Mesenteric Vein Thrombosis That Was Difficult to Diagnose and Caused Acute Deterioration

A Case of Superior Mesenteric Vein Thrombosis That Was Difficult to Diagnose and Caused Acute Deterioration

A Case of Acute Superior Mesenteric Vein Thrombosis Treated with Thrombolysis through a Recanalized Umbilical Vein

A Case of Acute Superior Mesenteric Vein Thrombosis Treated with Thrombolysis through a Recanalized Umbilical Vein