Splenic Vein Thrombosis Research Articles

S2732 Concurrent Development of Diabetes Mellitus, Splenic Vein Thrombosis, and Portal Vein Thrombosis Following a First Episode of Idiopathic Acute Pancreatitis: A Rare Triadic Presentation

S2732 Concurrent Development of Diabetes Mellitus, Splenic Vein Thrombosis, and Portal Vein Thrombosis Following a First Episode of Idiopathic Acute Pancreatitis: A Rare Triadic Presentation

Case of Splenic Infarction; A Rare Presentation of Complicated Enteric Fever in a Pediatric Patient

Background: The causative organism for enteric fever is Salmonella typhi, which has developed resistance to first-line antibiotics such as ampicillin, chloramphenicol, and TMP-SMX. Case Presentation: A 14-year-old boy presented to the emergency department with complaints of fever, chills, and rigors, as well as excessive sweating and LUQ abdominal pain, for a period of seven days. The boy also experienced vomiting and loose feces for three days. The abdominal examination revealed splenomegaly and LUQ tenderness. Salmonella typhi organism was isolated in blood cultures. Conclusions: Splenic vein thrombosis and infarction, a rare complication of S. Paratyphi infection, frequently cause discomfort in the left upper quadrant. In conjunction with supportive care, third-generation cephalosporins or quinolones are essential for effective treatment.

Simultaneous portal vein thrombosis and splenic vein thrombosis in a COVID-19 patient: A case report and review of literature

BACKGROUND It is well-described that the coronavirus disease 2019 (COVID-19) infection is associated with an increased risk of thrombotic complications. While there have been many cases of pulmonary emboli and deep vein thrombosis in these patients, reports of COVID-19 associated portal vein thrombosis (PVT) have been uncommon. We present a unique case of concomitant PVT and splenic artery thrombosis in a COVID-19 patient. CASE SUMMARY A 77-year-old-male with no history of liver disease presented with three days of left-sided abdominal pain. One week earlier, the patient was diagnosed with mildly symptomatic COVID-19 and was treated with nirmatrelvir/ritonavir. Physical exam revealed mild right and left lower quadrant tenderness, but was otherwise unremarkable. Significant laboratory findings included white blood cell count 12.5 K/μL, total bilirubin 1.6 mg/dL, aminoaspartate transferase 40 U/L, and alanine aminotransferase 61 U/L. Computed tomography of the abdomen and pelvis revealed acute PVT with thrombus extending from the distal portion of the main portal vein into the right and left branches. Also noted was a thrombus within the distal portion of the splenic artery with resulting splenic infarct. Hypercoagulable workup including prothrombin gene analysis, factor V Leiden, cardiolipin antibody, and JAK2 mutation were all negative. Anticoagulation with enoxaparin was initiated, and the patient’s pain improved. He was discharged on apixaban. CONCLUSION It is quite uncommon for PVT to present simultaneously with an arterial thrombotic occlusion, as in the case of our patient. Unusual thrombotic manifestations are classically linked to hypercoagulable states including malignancy and hereditary and autoimmune disorders. Viral infections such as Epstein-Barr virus, cytomegalovirus, viral hepatitis, and COVID-19 have all been found to increase the risk of splanchnic venous occlusions, including PVT. In our patient, prompt abdominal imaging led to early detection of thrombus, early treatment, and an excellent outcome. This case is unique in that it is the second known case within the literature of simultaneous PVT and splenic artery thrombosis in a COVID-19 patient.

Propylthiouracil-Induced Anti-Neutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis Presenting with Multiple Sterile Abscesses, Mononeuritis Multiplex, and Splenic Vein Thrombosis: A Case Report and Literature Review

Propylthiouracil-Induced Anti-Neutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis Presenting with Multiple Sterile Abscesses, Mononeuritis Multiplex, and Splenic Vein Thrombosis: A Case Report and Literature Review

Splenic, Ovary, and Renal Vein Thrombosis

Splenic, Ovary, and Renal Vein Thrombosis

Collateral after Splenic Vein Thrombosis

A 46-year-old man presented to the emergency department because of relapsing abdominal pain in the left abdominal quadrants. At admission, he was in good general condition and his vital signs were normal. The only abnormal laboratory findings were a C-reactive protein of 30 mg/L and thrombocytes of 127 G/L. An abdominal computed tomography (CT) scan showed a thrombosis of the distal splenic vein (panel A, double arrow) with the presence of a superior and an inferior spleno-mesenteric collateral (panel A, asterisks). The axial CT scan (panel V, arrows) and Doppler sonography (panel C) showed that the thick collaterals developed below the abdominal wall. A gastroscopy showed stage I fundic varices, but no esophageal varices. (1-10) This patient was diagnosed with a smoldering multiple myeloma 5 years earlier with regular follow-up in the hemato-oncology department. No other pro-thrombotic conditions were found and in a follow-up CT scan 6 months later the findings were un-changed despite anticoagulation. Splenic vein thrombosis is frequently diagnosed in the chronic stage, when collaterals have already developed (11-18). In this case, the presence of two major spontaneous shunts between the splenic vein and the superior mesenteric vein is preventing complications (19-23) such as porto-systemic encephalopathy and variceal bleeding

Abstract 1067: Floating Through The Aorta; Aortic Thrombus Takes It Course

Background: Aortic thrombus is an uncommon condition that is usually discovered as an incidental finding but in rare cases can be the cause of fatal conditions. The reported incidence of its intramural, pedunculated and floating types. The most common location is reported to be the descending aorta followed by the aortic arch. The pathophysiology remains unclear but possible predisposing factors include atherosclerosis, hypercoagulability disorders, malignancy, dissections, aneurysm, chronic inflammatory states, substance use and chronic steroid use. Treatment can vary from anticoagulation to thrombolysis and surgical removal based on the clinical presentation. Clinical presentation: 48-year-old male with a past medical history of hyperparathyroidism presented with three days of nausea, vomiting and lower abdominal pain. CT abdomen showed pancreatic inflammation and he was admitted for pancreatitis. MRCP was completed to evaluate for organic causes of pancreatitis which revealed left renal infarction. CTA C/A/P was done to evaluate infarction and was found to have large 1.5 x 1.1 x 2.1 cm mural thrombus, partially free-floating in distal thoracic aortic arch/proximal descending segment and focal narrowing at the origin left renal artery presumed to be of embolic origin. He was started on heparin drip for the rest of his hospital course and continued to improve. Hypercoagulable work up was unrevealing for any specific etiologies of the thrombus. Pancreatitis was determined as the presumed cause of thrombus as thromboembolism is a known possible complication of pancreatitis and splenic vein thrombosis may be seen in up to 12% of patients .Surgical intervention was initially considered, however repeat CT angiogram of chest/abdomen prior to discharge showed near resolution of thrombus with stable left renal infarct. He was discharged with apixaban and was recommended to follow-up outpatient. Conclusion: Aortic thrombus is rare due to the constant flow of pressure within the aorta. Early detection and management are crucial to avoid embolization which can lead to end organ dysfunction, limb ischemia, mesenteric ischemia, and stroke. DOAC anticoagulation is a viable and efficient therapy option if surgical intervention is not feasible

O127: Global DELPHI Consensus Study on anticoagulation for splanchnic vein thrombosis in acute pancreatitis

Abstract Introduction Splanchnic vein thrombosis (SpVT) occurs in 16.6%-22.6% of acute pancreatitis cases, influenced by pancreatitis severity and imaging techniques. Serious sequelae include hepatic and bowel failure, while management with anticoagulation remains controversial amidst perceived bleeding risks. This study's aim, driven by heterogeneity in literature, utilized DELPHI methodology to discern expert consensus on SpVT treatment, advocating for standardized research approaches. Methods Using purposive, non-probability sampling and DELPHI methodology, n=173 global experts in SpVT-related acute pancreatitis were engaged from international networks. From April 2022-2023, a three-round Delphi process was implemented to completion. n=26 statements were posed, spanning diagnosis, prognosis, management, and outcomes, with feedback via a 4-point Likert scale. By Round 3, n=54/173 participants remained. Results The mean acute pancreatitis caseload per expert per year was 68.0, 72.6 and 73.0 across successive DELPHI rounds. Regarding SpVT anatomical location, there was strong consensus favouring anticoagulation for portal vein (90.7%) and SMV thrombosis (92.6%), but no consensus to treat splenic vein thrombosis (48.2%). 83.7% advocated anticoagulation for complete thrombus occlusion and 70.9% for partial occlusion. Expert views on anticoagulation duration were dichotomous, with 40.7% endorsing 3 or 6 months. In DELPHI Round 3, 74.1% rejected radiological resolution as a definitive treatment endpoint. Conclusion Grading of recommendations for SpVT treatment is precluded by heterogeneity in the evidence base. This inaugural DELPHI study underscores the salient considerations for future research. Overwhelming consensus stratified treatment for SpVT localization and degree of thrombus occlusion. 94.5% of experts agree on the feasibility of RCT to investigate treatment of SpVT.

A314 UNDIFFERENTIATED PANCREATIC CARCINOMA WITH OSTEOCLAST-LIKE GIANT CELLS: A CASE REPORT

Abstract Background Pancreatic undifferentiated carcinoma with osteoclast-like giant cells (UCOGC) is a rare form of pancreatic cancer representing under 1% of cases. UCOGC is hypothesized to be a variant of pancreatic adenocarcinoma and while the pathophysiology is incompletely defined, it is felt to be an undifferentiated sarcomatoid carcinoma variant with chemotaxis of osteoclastic giant cells. Clinical, radiographic, or biochemical features do not reliably differentiate this from other tumors. Definitive diagnosis is made by histologic examination demonstrating non-neoplastic multinucleated osteoclastic giant cells (CD68 positive), mononuclear histiocytes, and neoplastic mononuclear cells. Aims To describe the case of a patient with UCOGC, highlighting key clinicopathologic features and management. Methods Case report and literature review. Results A 79-year-old man with atrial fibrillation on Xarelto presented with 4 months of abdominal pain, nausea, vomiting, and weight loss (22 kg). An MRI revealed a dilated main pancreatic duct and side branches with abrupt cutoff in the neck due to an ill-defined lesion. Endoscopic ultrasound confirmed a 36 mm hypoechoic ill-defined mass in the pancreatic neck. Biopsy performed with a 22-gauge needle with dry suction showed tissue fragments consistent with UCOGC (Figure 1). Unfortunately, the patient presented to hospital with worsened abdominal pain and nausea and was found to have new portal, superior mesenteric, and splenic vein thrombosis. His anticoagulant was changed to Dalteparin. A multidisciplinary cancer conference was held including input from experts in Toronto, and due to surrounding inflammation and new thrombosis he was not considered a surgical candidate at the time and neoadjuvant treatment with standard adenocarcinoma chemotherapy was planned. Unfortunately, the patient continued to decline and he was treated with palliative intent FOLFIRINOX for 2 cycles before opting for a medical assistance in dying procedure. Conclusions Treatment for UCOGC has not been well studied due to its rarity. Surgery is first-line therapy if appropriate based on patient status and cancer stage. The efficacy of chemotherapy and radiation is unclear but as a suspected adenocarcinoma variant, standard chemotherapy regimens are often used. Research is ongoing with an area of interest being PD-L1 inhibition due to high tumor PD-L1 positivity rates. Recognition of this rare entity is crucial due to its distinct diagnostic and therapeutic characteristics with more research needed to establish optimal therapy. Figure 1: Pathologic examination with HPS and CD68 stains demonstrating UCOGC Funding Agencies None

A Case Report of Modified Pancreatic Transplantation With a Limited Splenic Arteriovenous Fistula to Elude Thrombosis

In classic pancreatic transplantation, the splenic artery and vein are ligated at the tail of the pancreas graft. This leads to slowed blood flow in the splenic vein and may cause thrombosis and graft loss. In this study, a patient received a pancreas after kidney transplantation. A modified surgical technique was used in the pancreatic graft preparation. The donor splenic artery and vein were anastomosed end to end at the tail of the pancreas. The splenic artery near the anastomosis was partially ligated, and an effective diameter of 2 mm was reserved to limit arterial blood pressure and flow. The patient recovered very well. Contrasted computed tomography scans on days 11 and 88 after pancreas transplantation indicated sufficient backflow of the splenic vein. We believe that this procedure may avoid the risk of splenic vein thrombosis after pancreas transplantation. This modified technique has not been reported in clinical cases previously and may help reduce the risk of thrombosis after pancreas transplantation.

Splenic Vein Thrombosis as a Complication of Hypertriglyceridemia-Induced Acute Pancreatitis

Splenic Vein Thrombosis as a Complication of Hypertriglyceridemia-Induced Acute Pancreatitis

Splenomegaly and thrombocytopenia as findings of splenic vein thrombosis: not as common as you think

Splenomegaly and thrombocytopenia as findings of splenic vein thrombosis: not as common as you think

Rare Complication of Chronic Pancreatitis: Chronic Portal Vein Thrombosis and Splenic vein thrombosis causing non cirrhotic portal hypertension

Splenic vein thrombosis is a well-established complication of chronic pancreatitis, while portal vein thrombosis is a rare complication. In this case, we present an interesting instance of chronic pancreatitis associated with both portal and splenic vein thrombosis, causing non-cirrhotic portal hypertension. A fortysix-year-old male patient presented to us with clinical features of chronic pancreatitis. He underwent a CECT abdomen, which showed chronic pancreatitis with portal vein and splenic vein thrombosis. Screening for thrombophilic conditions and malignancies were negative. An upper gastrointestinal endoscopy showed fundal varices. Chronic portal vein thrombosis and splenic vein thrombosis are rare complications of chronic pancreatitis, which can cause non-cirrhotic portal hypertension.

Vaccine-Induced Thrombotic Thrombocytopenia (VITT) Associated with AstraZeneca Vaccine: A Comprehensive Review

Several vaccines have been approved to be used during the COVID-19 pandemic. However, serious concerns have been raised due to vaccine-induced thrombotic thrombocytopenia (VITT) reported with the AstraZeneca vaccine. This study is done to assess the vaccine's safety and summarize the background, evaluation, and management of a patient with VITT. Employing a meticulous literature search on PubMed and Google Scholar using keywords such as "AstraZeneca," "COVID-19 vaccine," "Clot," "Clots," "Thrombosis," and "Thrombus formation" in various combinations, 34 resources were identified, with 11 containing primary data on 28 documented VITT cases. The analysis revealed a gender distribution of 28.6% male and 71.4% female, spanning ages 22 to 74 years (median: 36 years). VITT symptoms manifested within 1 to 17 days post-vaccination. The predominant thrombotic sites were Central Venous Thrombosis, Splenic Vein Thrombosis, and Pulmonary Embolism. Notably, 46.4% of cases showed improvement, while 53.6% resulted in fatalities. This research underscores the rare but serious risk of vaccine-induced thrombotic thrombocytopenia associated with AstraZeneca vaccination, highlighting the importance of continued vigilance and monitoring in the ongoing global vaccination campaigns.

Multiple Splanchnic Venous Thromboses: A Fatal Complication of Recurrent Pancreatitis

Splanchnic Venous Thrombosis (SVT) is a condition associated with high morbidity. The etiologies of SVT include intra-abdominal inflammation or infection, surgical intervention, abdominal malignancies such as hepatocellular carcinoma (HCC) and pancreatic carcinoma, or abnormality in coagulation caused by various reasons such as liver cirrhosis. Most cases of pancreatitis are mild and self-limited. On the other hand, approximately one-quarter of patients with pancreatitis may develop vascular complications such as venous thrombosis. Pancreatitis associated with vascular complications is dangerous and potentially fatal. The survival of patients with pancreatitis and vascular complications depends on the early detection of these complications. We report a case of a middle-aged male who had recurrent pancreatitis. On radiological imaging, the patient was found to have a portal vein, splenic vein, and superior mesenteric vein thrombosis. The etiology of thrombosis was considered to be inflammation around the main portal trunk caused by pancreatitis Patient recovered after emergent and timely management with initially low molecular weight heparin and bridged by oral apixaban therapy. The article focuses on the aspects of etiology, pathogenesis, diagnosis, and management of acute pancreatitis with venous thrombosis. J Rang Med Col. September 2023; Vol. 8, No. 2: 60-63

THU365 Diabetic Ketoacidosis Unmasking Acute Pancreatitis With A Hidden Surprise

Abstract Disclosure: Y. Arya: None. A. Syal: None. S. Teja Sathi: None. J.V. Mayrin: None. Background: Development of diabetic ketoacidosis (DKA) in acute pancreatitis is rare and requires high clinical suspicion, particularly in cases such as ours where it might lead to presentation and hence, unmasking of pancreatitis. Our case was also complicated by splenic vein thrombosis, making it a therapeutic dilemma. Case Presentation: We describe the case of a female in her mid-40s who presented to the emergency department with complaints of severe epigastric abdominal pain, associated with vomiting, for the past one day. She was hemodynamically stable, and her laboratory analysis revealed a lipase greater than twenty times the upper limits of normal. Patient was also noted to have a random capillary blood glucose of 500 mg/dL with positive urine beta hydroxybutyrate and an anion gap of thirty-five. She was diagnosed with DKA and managed with intravenous (IV) insulin along with IV fluids. Her abdominal pain failed to respond which triggered us to obtain imaging. She underwent a computed tomography (CT) scan of her abdomen and pelvis which showed extensive pancreatic inflammation and necrosis along with peripancreatic fluid collection extending into the mesentery. The patient was managed with a multidisciplinary approach involving endocrinology, gastroenterology, and critical care teams. Her abdominal pain initially improved, followed by worsening around the sixth hospital day. She underwent an MRI of her abdomen which revealed a new splenic vein thrombosis. Given the risk of bleeding from the peri-pancreatic fluid collection and non-occlusive nature of the thrombosis, clinical monitoring was preferred over anticoagulation. Extensive workup did not reveal an etiology of the pancreatitis, and it was deemed idiopathic. The patient became insulin dependent from her pancreatitis. She had a prolonged hospital course and was eventually discharged after three weeks of presentation with appropriate outpatient follow-up. Discussion: The incidence of diabetes mellitus after acute pancreatitis depends on the severity of pancreatic necrosis; the degree of insulin deficiency being directly proportional to the extent of necrosis.[1] The pathophysiology of splenic vein thrombosis revolves around necrosis, venous stasis, and activation of coagulation cascade, all in the background of the inflammatory state.[2] Anticoagulation in splenic vein thrombosis secondary to pancreatitis thus remains controversial, given the increased risk of hemorrhage and formation of pseudoaneurysms. Interestingly, therapeutic anticoagulation might prevent thrombosis progression by reducing portal pressure and thereby decreasing the risk of hemorrhage. Lower rates of hemorrhage have been documented in literature in patients receiving anticoagulation in this subset of patients, versus untreated cases.[3] Thus, an individual risk-benefit analysis is needed before initiating anticoagulation.

S3434 Dehydration Causing Portal Vein, and Splenic Vein Thrombosis in a Healthy Adult

S3434 Dehydration Causing Portal Vein, and Splenic Vein Thrombosis in a Healthy Adult

Paroxysmal Nocturnal Hemoglobinuria: A Case Report in a Pandemic Environment

Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal, rare, complement-mediated hemolytic anemia. PNH can be associated with marrow failure and thrombophilia. We present a clinical report of splenic vein thrombosis in a patient with classic PNH. A 41-year-old male with classic PNH, naïve to complement inhibitor therapy, developed splenic vein thrombosis as a major adverse effect after vaccination protocol to prevent meningococcal disease. We also report anticoagulant and eculizumab treatment outcomes. In PNH patients, vaccination should be monitored to prevent major outcome events, like vaccine-induced thrombosis. Eculizumab proves effective for treating intravascular hemolysis and preventing more thrombotic events. The potential protective role of eculizumab on controlling complement activity and consequent inflammation may help the patient to not experience breakthrough hemolysis when infected with SARS-CoV-2. Extravascular hemolysis remains present, but new molecules are being studied to inhibit proximal complement and there is a good health prospective for PNH patients.

An Unusual Presentation ofSCAD ina Young Male Soldier.

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of myocardial infarction and sudden cardiac death in young individuals without significant cardiovascular risk factors. The etiology of SCAD appears to be multifactorial and is often precipitated by physical and emotional stress superimposed on underlying arteriopathy, connective tissue disorders, systemic inflammatory disorders, genetic factors, and hormonal influences. There are no current societal guidelines to stratify young soldiers' risk of developing SCAD. Diagnosis typically requires invasive coronary artery angiography which is largely unavailable in stations with limited medical resources. Furthermore, young patients with SCAD often present with atypical cardiac symptoms, such as heartburn leading to the misdiagnosis of gastroesophageal reflux disease and a delay in diagnosis and management. We present a 21-year-old active duty male who was transferred from Okinawa, Japan to a tertiary military medical center for evaluation of hypercoagulable conditions after CT revealed non-obstructing portal venous thrombosis extending to right hepatic vein, splenic vein thrombosis with splenic infarct, and bilateral wedge-shaped renal infarct. Extensive work-up ultimately revealed mid-left anterior descending spiral dissection with transmural infarct of inferior, anteroseptal, and inferoseptal wall resulting in the formation of left ventricular thrombus, subsequently causing thromboembolism to multiple organs. This case demonstrates the ramifications of SCAD when diagnosis and management are delayed and serve as a poignant reminder for all providers to include SCAD in the differential diagnosis for young soldiers with atypical chest pain.

Splanchnic vein thrombosis associated with SARS-CoV-2 infection: A VALDIG case–control study

Whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a risk factor for splanchnic vein thrombosis (SVT) is unknown. This study aims to assess the impact of SARS-CoV-2 infection on the presentation and prognosis of recent SVT and to identify specific characteristics of SARS-CoV-2-associated SVT. This is a retrospective study collecting health-related data of 27 patients presenting with recent SVT in the context of SARS-CoV-2 infection in 12 Vascular Liver Disease Group (VALDIG) centres and in comparison with 494 patients with recent SVT before the SARS-CoV-2 pandemic. Twenty-one patients with SARS-CoV-2 had portal vein thrombosis with or without thrombosis of another splanchnic vein, two had superior mesenteric vein thrombosis, one had splenic vein thrombosis, and three had hepatic vein thrombosis. Diagnosis of SVT was made 10 days (95% CI 0-24 days) after the diagnosis of SARS-CoV-2 infection. Fever (52 vs. 15%; p <0.001) and respiratory symptoms (44 vs. 0%; p <0.001) were more frequent, and median lymphocyte count was lower (1.1×103/mm3vs. 1.6×103/mm3; p= 0.043) in patients with infection than in those without SARS-CoV-2 infection. A prothrombotic condition was identified in 44 and 52% of patients with and without SARS-CoV-2 infection, respectively (p= 0.5). All patients with SARS-CoV-2 received anticoagulation therapy. During a median follow-up of 250 days, three SARS-CoV-2-infected patients (11%) required intestinal resection for infarction 1 to 3 months after diagnosis of SVT compared with 13 (2.6%) controls (p= 0.044). Partial or complete recanalisation of the thrombosed splanchnic vein was performed in 33% of patients with SARS-CoV-2. SARS-CoV-2 infection can be associated with recent SVT. Intestinal infarction leading to intestinal resection might be more frequent in patients with SARS-CoV-2. SARS-CoV-2 infection can be associated with recent SVT. SVT occurring during SARS-CoV-2 infection is characterised by a higher frequency of respiratory symptoms and a lower lymphocyte count. Intestinal infarction leading to intestinal resection appears to occur more frequently in patients with SARS-CoV-2.