Superior Mesenteric Vein Thrombosis Research Articles

Chronic Superior Mesenteric Venous Thrombosis Complicated With Protein-Losing Enteropathy and Massive Duodenal Bleeding in a Patient With HIV Infection: A Case Report

Chronic superior mesenteric vein thrombosis (SMVT) is a rare condition with favorable prognosis. We report a patient with HIV infection and chronic SMVT who presented with chronic diarrhea associated with protein-losing enteropathy (PLE) and subsequently he developed massive overt gastrointestinal bleeding (OGIB). A 46-year-old man had been diagnosed as HIV infection for 24 years. Ten years earlier, he had disseminated mycobacterial avium complex (MAC) associated with intra-abdominal lymphatic obstruction. As a consequence, SMVT without evidence of cirrhosis was detected by CT scan of the abdomen. He received antiretroviral agents. CD4 level was 213 cells/mm3 (17%CD4) and his viral load was 318 copies/ml. In addition, a long-standing of oral estrogen was used for inducing his female characteristics. He was referred to our hospital because of chronic watery diarrhea, hypoalbuminemia, and generalized edema for 6 months. Physical examination showed ascites and legs swelling. During hospitalization, he developed massive hematochezia. After blood transfusion, gastroscopy, colonoscopy, and CT angiography were performed. The bleeding source was not identified. CT scan of the abdomen revealed SMV obliteration with increased collateral vessels and bowel wall thickening (Figure 1). Subsequently, ectopic varices were suspected. Push enteroscopy was performed and showed varices at the third part duodenum with blood clot on top and endoscopic therapy with glue injection was successfully done (Figure 2). 99mTc-human serum albumin scan showed radiotracer accumulation in small bowel (Figure 3). Stool microbiology, histopathology of small bowel and colon were negative for mycobacterium, parasites and malignancy. Therefore chronic SMVT secondary from intra-abdominal infection complicated with PLE and massive bleeding of duodenal varices was diagnosed.Figure 1Figure 2Figure 3The cause of SMVT in this patient was due to intra-abdominal inflammation from the previous disseminated MAC infection combined with acquired thrombophilia by estrogen. The chronic obliteration of SMV raised mesenteric venous pressure and the development of dilated venous collaterals, these in turns resulted in variceal formation as ectopic varices. We speculate that SMVT could further block lymphatic drainage; and cause intestinal lymphangiectasia and PLE from lymphatic leakage.

Valproic Acid-Induced Necrotic Pancreatitis With Superior Mesenteric Vein Thrombosis: Case Report and Literature Review

Valproic Acid-Induced Necrotic Pancreatitis With Superior Mesenteric Vein Thrombosis: Case Report and Literature Review

Superior Mesenteric Venous Thrombosis: Paraneoplastic Manifestation of a Rare Renal Cell Carcinoma

Mesenteric venous thrombosis is a rare but lethal form of mesenteric ischemia and it is a well-established cause of intestinal ischemia. Malignancy is recognized as an important risk factor. Multilocular cystic renal cell carcinoma (MCRCC) is a rare cystic tumor of the kidney with a good prognosis and in most of the cases the diagnosis is made incidentally. A 69-year-old man with a past medical history of arterial hypertension, dyslipidemia and coronary artery bypass surgery, presented in the emergency department with colic abdominal pain. His abdominal examination was notable for tenderness in the right iliac fossa on palpation and laboratory work-up revealed leukocytosis 13x109 U/L and elevated C-reactive Protein (33 mg/L). Contrast-enhanced computed tomography (CT) showed hypoenhancing wall thickening of the distal ileum (50 cm) and a filling defect within the superior mesenteric vein, consistent with ischemia of a large segment of the ileum (Figure 1). Small bowel resection of 70 cm of ileum was performed with primary anastomosis (Figure 2). The prothrombotic study did not reveal Protein C, Protein S and antithrombin III deficiency or factor V Leiden mutation. Myeloproliferative disorders were also excluded. Six months later, a contrast enhanced CT showed in the middle part of the right kidney a heterogeneously enhancing, well-defined, mass lesion with 33 mm (Figure 3). This lesion was previously described in the first CT scan and maintained the same dimensions. Nonetheless, since cystic renal cell carcinoma could not be excluded, a right-sided nephrectomy was performed. The gross examination of the kidney revealed a cystic lesion of 2.8 × 1.5 cm dimension containing mucinous material. Histopathological examination revealed a MCRCC staged as pT1a Nx R0.Figure 1Figure 2Figure 3Herein we describe a patient with mesenteric venous thrombosis without inherited prothrombotic conditions, abdominal surgeries or traumatic injuries. Additional investigation showed that the probable cause for the thrombotic event was a rare renal cell cancer (MCRCC). To the best of our knowledge, this is the first case described in the literature of small intestinal ischemia secondary to superior mesenteric vein thrombosis associated with a MCRCC. In fact, cancer is recognized as an important condition that predisposes patients to a hypercoagulable state and therefore a risk factor for trombothic events. This case highlights the importance of identifying the underlying pathology which leads to thrombosis as it conditionates the long-term management and well-being of these patients

A Rare Case of Isolated Superior Mesenteric Vein Thrombosis in an Elderly Woman With Late-Onset Anti-Phospholipid Syndrome

A Rare Case of Isolated Superior Mesenteric Vein Thrombosis in an Elderly Woman With Late-Onset Anti-Phospholipid Syndrome

The incidence and risk factors of portal vein system thrombosis after splenectomy and pericardial devascularization.

This study aimed to investigate the incidence and risk factors of portal vein system thrombosis (PVST) in patients with liver cirrhosis after splenectomy and pericardial devascularization. We retrospectively analyzed 71 patients who underwent splenectomy with pericardial devascularization for portal hypertension due to cirrhosis. Patients were categorized into Group A (n=23): early prophylactic anticoagulants therapy; Group B (n=29): late prophylactic anticoagulants therapy; and Group C (n=19): no anticoagulation therapy. Univariate and multivariate analyses of the risk factors of PVST were performed. The incidence of PVST and the effect of thrombolytic therapy were evaluated. Multivariate analysis revealed a wider preoperative splenic vein diameter (≥8 mm), and lower preoperative platelet counts (<50×109/L) were significantly correlated with PVST development. The incidence of PVST in Groups A, B, and C was 26.1% (6/23), 44.8% (13/29), and 52.6% (10/19), respectively (all p>0.05). The complete resolution rate of portal, superior mesenteric, and splenic vein thrombosis was 75%, 62.5%, and 23.8%, respectively. A wider preoperative splenic vein diameter and lower preoperative platelet counts are independent risk factors of PVST. Early anticoagulation therapy had a tendency towards a reduced incidence of PVST, but it was not statistically significant. The complete resolution rate of splenic vein thrombosis was lower than that of portal and superior mesenteric vein thrombosis.

Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with variceal bleeding in liver cirrhosis: outcomes and predictors in a prospective cohort study.

The role of transjugular intrahepatic portosystemic shunt (TIPS) for the secondary prophylaxis of variceal bleeding in cirrhotic patients with portal vein thrombosis (PVT) remains obscure. This prospective cohort study aimed to assess the risk factors associated with TIPS technical success, outcome and prognosis in cirrhotic patients with PVT and a history of variceal bleeding. Between May 2009 and April 2011, 51 cirrhotic patients with PVT who attempted TIPS procedures for the prevention of variceal rebleeding were enrolled. TIPS success rate was 84% (43/51). An increased degree of thrombosis within the portal trunk and portal vein branches was inversely associated with TIPS success. Median follow-up time was 40.07months (range: 0.02-56.87). The cumulative risk of rebleeding was significantly different between TIPS success and failure group (P=0.002). The univariate analysis also demonstrated that TIPS failure was the only significant predictor associated with rebleeding (hazard ratio [HR]=4.174, 95% confidence interval [CI]: 1.558-11.186). In TIPS success group, the cumulative rates free of shunt dysfunction at the 6th and 12th month were 79% and 76% respectively. Absence of total superior mesenteric vein (SMV) thrombosis was the only independent predictor (HR=0.189, 95% CI: 0.047-0.755). In TIPS success group, the 1- and 3-year cumulative survival rates were 77% and 62% respectively. Albumin level was the only independent predictor (HR=0.877, 95% CI: 0.779-0.986). Successful TIPS insertions could effectively prevent from rebleeding in cirrhotic patients with PVT and variceal bleeding. Degree of PVT and SMV thrombosis was associated with TIPS failure and shunt dysfunction respectively.

Recurrent abdominal pain after an episode of acute diverticulitis

A 60-year-old man was hospitalized because of acute diverticulitis complicated with Bacteroides fragilis bacteremia. The computed tomography (CT) scan showed cecal diverticulitis with superior mesenteric vein (SMV) thrombosis (Fig. 1). At that time, he received parenteral antibiotics for 2 weeks and then oral antibiotics for 1 week after discharge. Nine days later, he presented to our emergency department with progressive abdominal pain and fever. CT scan demonstrated improved diverticulitis but progressive local peritoneal inflammation around the SMV thrombosis (Fig. 2). Septic thrombophlebitis is venous thrombosis-associated inflammation with positive blood culture results. It is an uncommon complication of intra-abdominal infections such as cholangitis, diverticulitis, and appendicitis. Septic thrombophlebitis carries a high mortality risk if patients do not receive adequate treatment [1]. Septic thrombophlebitis may involve superficial veins or deep veins such as

Superior Mesenteric Vein Thrombosis in a Nursing Home Resident

Although mesenteric venous thrombosis is an uncommon diagnosis, it was first described in the late fifteenth century. During the mid-nineteenth century, further interest in the pathophysiology and treatment of mesenteric venous thrombosis began to emerge. In 1895, the first documented successful resection and re-anastomosis of the mesenteric vasculature was completed on a patient presenting with gangrenous bowel. Outcomes of this condition vary based upon the acuity and severity of the clinical presentation, and may include bowel necrosis, peritonitis, sepsis, and death.

Suppurative Duodenitis and Superior Mesenteric Vein Thrombosis After Toothpick Ingestion

Suppurative Duodenitis and Superior Mesenteric Vein Thrombosis After Toothpick Ingestion

Isolated Superior Mesenteric Vein Thrombosis in Acute Pancreatitis: A Case Report

The most common vascular complication of acute pancreatitis is thrombosis of the splenic vein. Isolated thrombosis of the superior mesenteric vein is rare and may lead to mesenteric ischemia and bowel infarction. We report the case of a 39 years old patient received for acute pancreatitis with a Ranson score less than 3 and image scanner for a grade C of Balthazar and a superior mesenteric vein thrombosis. The outcome was favorable with improvement of symptoms under medical treatment including anti-coagulant therapy. The contrast enhancing abdominal CT showed an absence of superior mesenteric thrombosis.

Acute Superior Mesenteric Vein Thrombosis in a Patient with Primary Antiphospholipid Syndrome: A Case Report and Brief Review of the Literature

Acute superior mesenteric vein thrombosis is an uncommon but life threatening disease condition. In the setting of antiphospholipid syndrome, it is rare. This is a case of a 49 year old male who presented with a 2 day history of nausea, vomiting and abdominal pain. He had a previous history of deep vein thrombosis and pulmonary embolism about a year ago. Triple phase computed tomography confirmed superior mesenteric vein thrombosis. Lupus anticoagulant antibody was positive. He was initiated on heparin and then transitioned to warfarin. Given the finding of primary antiphospholipid syndrome, he is currently on lifelong anticoagulant therapy. Surgical resection, site directed thrombolysis and thrombectomy are other options of treatment for acute superior mesenteric vein thrombosis. With the diagnosis of acute superior mesenteric venous thrombosis, with or without any identifiable triggering factor, a search for hypercoagulable state is indicated. This will help determine the duration of anticoagulation therapy and prevent recurrent thrombosis. Acute Superior Mesenteric Vein Thrombosis in a Patient with Primary Antiphospholipid Syndrome: A Case Report and Brief Review of the Literature.

腹腔鏡手術後に上腸間膜静脈・門脈血栓症をきたした上行結腸憩室症の1例

上行結腸憩室症に対する腹腔鏡下大腸切除術後に発症した上腸間膜静脈（SMV）・門脈（PV）血栓症の1例を経験したので報告する．症例は57歳，男性．血液検査でHgbが17.6g/dl，Hctが51.0％と高値であった．上行結腸憩室症に対して待機的に腹腔鏡下回盲部切除術を施行した．術後18日目に心窩部痛と背部痛を生じ，CT検査でSMVとPVにおける血栓を認めた．直ちにヘパリン，ウロキナーゼとワーファリンの投与を開始し，7日後にワーファリンの単独投与へ移行した．術後92日目のCT検査で血栓はSMVの分枝の一部に残存するのみであった．腹腔鏡下大腸切除術後に発症したSMV・PV血栓症は極めてまれである．自験例について，炎症を伴わない待機手術であったことから赤血球増多の状態に加えて，手術に伴う何らかの要因により発生した可能性が高いものと考えられた．

保存的治療が奏効したプロテインC欠損症に伴う上腸間膜静脈血栓症の1例

保存的治療が奏効したプロテインC欠損症に伴う上腸間膜静脈血栓症の1例

門脈ガス血症と上腸間膜静脈血栓症を合併したCrohn病の1例

症例は31歳，女性．Crohn病のため当院内科で内服加療中であったが，今回下腹部痛と発熱を主訴に受診した．来院時下腹部に圧痛を認めるものの，反跳痛・腹膜刺激症状は認めなかった．腹部CTでは回盲部にfree airを，肝内に樹枝状に広がる門脈内ガス像および上腸間膜静脈血栓を認めたため，Crohn病を背景とした回腸穿孔と判断し，緊急開腹手術を施行した．術中所見は，回結腸静脈と回腸静脈最終枝を索状に硬く触知し，同静脈血栓症と判断し回盲部切除を行った．病理組織学的所見上，回腸末端に穿孔部を認め縦走潰瘍を伴いCrohn病と矛盾しなかった．静脈血栓は化膿性血栓静脈炎であった．術後経過は良好で術後28日に退院した．門脈ガス血症は従来，腸管壊死を伴う虚血性腸疾患の重篤な合併症とされているが，稀ではあるがCrohn病に時に合併する．自験例では早期に診断し，開腹手術に踏み切ったことで救命しえたと考えられた．

A Case of Idiopathic Superior Mesenteric Vein Thrombosis that Developed After Outdoor Labor in Hot Summer Weather

A Case of Idiopathic Superior Mesenteric Vein Thrombosis that Developed After Outdoor Labor in Hot Summer Weather

Mesenteric Vein Thrombosis Associated to Elevated Factor VIII in a Patient Treated with Adjuvant Tamoxifen

Introduction: Venous thrombosis is a well documented adverse effect in about one percent of patients treated with tamoxifen. Although the precise role of elevated factor VIII in defining venous thrombotic risk is not well understood, current data suggest that factor VIII is an independent risk factor for venous thrombosis.Methods: Case report.Results: In May 2011, a 76-year-old male underwent right modified radical mastectomy in May 2011. Tumor was a 2.5 cm well-differentiated, invasive ductal carcinoma, with lymphatic invasion present and widely negative surgical margins. The patient (pt) had one ipsilateral axillary lymph node (out of 26 sampled) with two microscopic foci (<1 mm) of metastatic ductal carcinoma. Additional evaluation on the mastectomy specimen showed that estrogen and progesterone receptors were strongly positive, Ki-67 was 25% and HER-2/neu showed negative (0 expression) by immunochemistry. The patient had no family history of venous thromboembolic events, and he had never smoked. His past medical history was significant for hypothyroidism and hypertension, both under good control. In June 2011 pt was started on adjuvant Tamoxifen 20 mg daily. In July of 2013 pt started with diffuse, ill-localized abdominal pain. No associated abdominal cramping, fever or nausea. No evidence of melena or rectorrahgia. An abdominal magnetic resonance imaging showed the presence of a superior mesenteric vein thrombosis. Tamoxifen was at that time discontinued and pt was started on enoxaparin 1 mg/Kg twice a day, with complete resolution of his symptoms within 7 days. Pt remained anticoagulated with enoxaparin for six months. After discontinuation of anticoagulation, radiologic and laboratory evaluation showed no evidence of underlying hypercoagulable state except for an elevation of serum factor VIII (> 150 IU/dl) that has persisted during his follow-up.Conclusions: Our case supports the notion that high levels of factor VIII are a risk factor for venous thrombosis. DisclosuresNo relevant conflicts of interest to declare.

Rational classification of portal vein thrombosis and its clinical significance.

Portal vein thrombosis (PVT) is commonly classified into acute (symptom duration <60 days and absence of portal carvernoma and portal hypertension) and chronic types. However, the rationality of this classification has received little attention. In this study, 60 patients (40 men and 20 women) with PVT were examined using contrast-enhanced computed tomography (CT). The percentage of vein occlusion, including portal vein (PV) and superior mesenteric vein (SMV), was measured on CT image. Of 60 patients, 17 (28.3%) met the criterion of acute PVT. Symptoms occurred more frequently in patients with superior mesenteric vein thrombosis (SMVT) compared to those without SMVT (p<0.001). However, there was no significant difference in PV occlusion between patients with and without symptoms. The frequency of cavernous transformation was significantly higher in patients with complete PVT than those with partial PVT (p<0.001). Complications of portal hypertension were significantly associated with cirrhosis (p<0.001) rather than with the severity of PVT and presence of cavernoma. These results suggest that the severity of PVT is only associated with the formation of portal cavernoma but unrelated to the onset of symptoms and the development of portal hypertension. We classified PVT into complete and partial types, and each was subclassified into with and without portal cavernoma. In conclusion, neither symptom duration nor cavernous transformation can clearly distinguish between acute and chronic PVT. The new classification system can determine the pathological alterations of PVT, patency of portal vein and outcome of treatment in a longitudinal study.

Small Bowel Obstruction: A Novel Complication of Superior Mesenteric Vein Thrombosis

Introduction: Superior mesenteric vein thrombosis (SMVT) is rare condition, and it accounts for 1 in 5,000 inpatient admissions for abdominal pain. It is usually an incidental finding or a diagnosis found during work-up of abdominal pain. Intestinal infarction is one of its well-recognized complications. Here, we report an unusual case of small bowel obstruction (SBO) secondary to SMVT. A 71-year-old woman with a history of colon cancer (had chemotherapy and transverse hemicolectomy 5 years ago) presented with complains of persistent vomiting for the past 2 days and abdominal pain for 1 day. Her vital signs were temperature 98° F, pulse 90 beats/minute, blood pressure 120/70 mm Hg. Physical examination was remarkable for distended abdomen with no rigidity or guarding. Laboratory work showed metabolic acidosis with lactic acid 5.77 mg/dL, hemoconcentration (hematocrit 46%). CT abdomen with contrast showed SBO due to an ill-defined mass at the ileo-transverse colonic anastomosis, which was contiguous with the mural thickening. It also showed bowel wall edema, SMVT (Figure 1) and superior mesenteric artery (SMA) narrowing. Surgical intervention was planned, but was not done, as the patient preferred conservative management. She responded well to hydration and nasogastric suction with resolution of lactic acidosis. She tolerated regular diet before discharge. During her third admission within a month with similar presentation, CT scan abdomen was repeated, which showed interval resolution of ileo-transverse colonic mass as seen on previous imaging, unchanged bowel edema, SMVT, and narrowing of SMA. Small bowel follow-through confirmed absence of luminal obstruction along with non-uniform caliber of the small bowel consistent with SMVT. She was diagnosed as a case of SMVT presenting as SBO. She was managed with therapeutic anticoagulation and a clear liquid diet, which was later transitioned to regular diet. To the best of our knowledge, this is the first case of SMVT presenting as SBO. A high index of suspicion is required to diagnose SMVT as a cause of SBO since early initiation of therapeutic anticoagulation forms the essential component of management.Figure 1: SMVT (arrow).

Superior Mesenteric Vein Thrombosis in a Patient Heterozygous for Factor V Leiden Mutation and With a History of Sleeve Gastrectomy

Introduction: Superior mesenteric vein thrombosis (SMVT) presents as abdominal pain in the acute setting. Associations with thrombophilia’s as well as intra-abdominal laprascopic surgeries have been described in the literature. In spite of the known predisposition to thrombosis in this patient population no specific hypercoaguability screening is recommended by the Society of American Gastrointestinal and Endoscopic Surgeons for patients who will be undergoing laparoscopic bariatric surgery. We present a case of 46-year-old male who developed acute SMVT two years after laparoscopic sleeve gastrectomy, and was subsequently found to be heterozygous for a Factor V Leiden (FVL) mutation. Case Report: A 46-year-old male presented with complaints of epigastric pain, radiating to his back for approximately 2 days. The pain was described as crampy in nature and worsened by food. The patient denied any nausea, vomiting, or change in his bowel function. The patient had undergone a vertical laparoscopic sleeve gastrectomy two years earlier. Laboratory workup including amylase and lipase were found to be normal. CT scan of the abdomen and pelvis with contrast showed a SMVT. There was no arterial occlusion or extension of the venous thrombus. Heparin infusion was started and the patient was transitioned to oral Coumadin therapy. Subsequent hypercoaguable workup for antithrombin III, protein-C and S and anticardiolipin were all negative. However, the patient was found to be FVL heterozygous, and on repeat questioning reported familial history of the disorder. Conclusion: SMVT in patients who have undergone laprascopic surgery generally occurs in the acute postoperative setting and in association with pneumoperitoneum induced hemodynamic changes, hypercapnia induced mesenteric vasoconstriction, and coagulation impairment. Our case is unique in that the patient was 2 years removed from his sleeve gastrectomy before developing a SMVT. Our patient was found on subsequent hypercoaguable work-up to be heterozygous for FVL mutation. Local inflammatory processes and thrombophilia’s are known risk factors for the development of SMVT, with one retrospective case review finding a prothrombotic defect in 75% of patients, 25% of which were heterozygous for a FVL mutation. Although case reports have been written linking both bariatric surgery and thrombophilia’s to SMVT, our case is unique in the duration of time that passed before our patient presented with his thrombosis. Our case raises the question of while it may not be financially feasible to screen all patients undergoing surgery, should there be special consideration for patients with a familial history of thrombophilia’s given their risk of development of SMVT.

A Curious Case of a Rapid Resolution of Acute Tubular Necrosis After Portal Vein Decompression in a Cirrhotic Patient With Underlying Hepatorenal Syndrome: A Case Report and Literature Review

Introduction: Acute kidney injury is a common complication in cirrhosis and is associated with a poor prognosis. Splanchnic vasodilatation triggered by portal hypertension with subsequent renal vasoconstriction appears to play a central role in the hemodynamic changes and the decline in renal function in cirrhotic patients. We report a case of a 54-year-old female with decompensated alcoholic cirrhosis and underlying type 2 hepatorenal syndrome (HRS) based on a low urine sodium and bland urinalysis, who presented with confusion and abdominal pain. Abdominal duplex ultrasound revealed acute non-occlusive portal and superior mesenteric vein thrombosis with increased portal pressure. The patient subsequently developed acute tubular necrosis (ATN) with a serum creatinine of 4.0 mg/dL from a baseline of 0.9 mg/dL. The diagnosis was made based on high urine sodium and the presence of urinary granular cast. Due to worsening renal function, hemodialysis was initiated. Mechanical thrombectomy of the superior mesenteric and portal vein thrombus was performed with a substantial decrease of portal pressure. Her renal function recovered significantly and returned to baseline 4 days after the procedures. In conclusion, a rise in portal pressure from extensive portal vein thrombosis in this case led to the profound renal hypoperfusion and worsening of HRS which led to ATN. Thus, decompression of portal hypertension and reversal of hemodynamics using TIPS and mechanical thrombectomy might have beneficial effects in other cirrhotic patients with similar presentation. Further studies are warranted to prove this theory.Figure 1Figure 2