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Mesenteric Vein Thrombosis

Mesenteric vein thrombosis is a potentially life-threatening vascular disorder of the mesenteric venous system, which can arise due to numerous genetic, circulatory, neoplastic, infectious or iatrogenic conditions. Both acute and chronic forms have been described in the literature. Imaging studies, primarily contrast-enhanced computed tomography, are used to make the diagnosis.


Presentation

A number of conditions can cause mesenteric vein thrombosis, a vascular abnormality that is responsible for about 5-15% of all cases of mesenteric ischemia [1] [2]. Inherited coagulopathies and thrombophilias (antithrombin, protein C, protein S, or factor V Leiden deficiencies), local disorders (pancreatitis, diverticulitis, peritonitis, and other inflammatory diseases), obesity, neoplasias, hematological disturbances (particularly thrombocytopenia and polycythemia vera), soft tissue trauma, previous abdominal surgery, but also liver cirrhosis and stasis of the venous blood flow are some of the most important etiologies [1] [3] [4] [5]. In a large number of cases (between 20-50%), however, the exact cause remains unclear, in which case the term idiopathic mesenteric vein thrombosis is used [1] [3] Typical patients are aged between 40-60 years and are more commonly males [3]. The clinical presentation of mesenteric vein thrombosis (MVT) is divided into acute and chronic forms. In the acute setting, a sudden onset of nonspecific abdominal pain is the principal manifestation, followed by nausea, vomiting, diarrhea and gastrointestinal bleeding (hematemesis, hematochezia, or melena) [1] [3] [6]. Mesenteric ischemia and bowel infarction are life-threatening complications of acute MVT, manifesting as dehydration, hypotension, fever, ascites, and shock [1]. Unfortunately, several studies have confirmed that the majority of patients (about 75%) are symptomatic for days before being diagnosed, putting them at a life-threatening risk [3]. A chronic course, on the other hand, may be completely asymptomatic, but persistent abdominal pain and edema are frequently reported [1] [3]. Malnutrition is also a frequent manifestation, which is why many individuals require parenteral nutrition, whereas existing portal hypertension could lead to hemorrhage from esophageal varices [1] [3] [6].

Fever
  • One of them had appendectomy and developed fever 10 days postoperatively. The other was treated conservatively.[ncbi.nlm.nih.gov]
  • A 56-year-old female presented to our hospital with complaints of fever and diarrhea.[oatext.com]
  • Mesenteric ischemia and bowel infarction are life-threatening complications of acute MVT, manifesting as dehydration, hypotension, fever, ascites, and shock.[symptoma.com]
  • J Clin Invest 31: 621-2 Resat O, Birgul M, Elif H, Ali M, Fehmi T (2003) Primary antiphospholipid syndrome: a cause of fever of unknown origin. Intern Med. 42: 358-361.[omicsonline.org]
Severe Pain
  • SMV Thrombosis is a rare condition that can cause an array of symptoms, from severe pain to diarrhea [1].[oatext.com]
Down Syndrome
  • A 32-year-old-man with Down syndrome presented with abdominal pain and was found to have extensive porto-splenomesenteric thrombosis with early bowel ischemia on computed tomography.[ncbi.nlm.nih.gov]
Abdominal Pain
  • We report a case of a 59-year-old man with a history of chronic obstructive pulmonary disease (COPD) stage III, who presented with abdominal pain.[ncbi.nlm.nih.gov]
  • Furthermore, the differential diagnosis of nonspecific abdominal pain and associated symptoms is quite broad.[symptoma.com]
Vomiting
  • She presented with abdominal pain and vomiting, initially diagnosed with portal and superior mesenteric vein thrombosis. Immunophenotyping by flow cytometry revealed a diagnosis of paroxysmal nocturnal haemoglobinuria type III.[ncbi.nlm.nih.gov]
  • In the acute setting, a sudden onset of nonspecific abdominal pain is the principal manifestation, followed by nausea, vomiting, diarrhea and gastrointestinal bleeding (hematemesis, hematochezia, or melena).[symptoma.com]
  • Case Report A 47 years old male patient was admitted to our hospital complaining of recurrent attacks of vomiting for 3 months. His condition started with a gradual onset of vomiting associated with epigastric pain, anorexia and weight loss.[pubs.sciepub.com]
  • Abstract A 66-year-old man admitted for abdominal pain and vomiting was found in abdominal contrast-enhanced computed tomography to have a thrombus of the superior mesenteric vein and thickened small-intestine walls.[jstage.jst.go.jp]
Nausea
  • In the acute setting, a sudden onset of nonspecific abdominal pain is the principal manifestation, followed by nausea, vomiting, diarrhea and gastrointestinal bleeding (hematemesis, hematochezia, or melena).[symptoma.com]
  • In this case, abdominal pain, nausea, vomiting and diarrhea appeared nine days after surgical procedure.[thejh.org]
  • Acute superior mesenteric vein thrombosis most frequently presented as abdominal pain (83%), anorexia (53%), nausea and vomiting (50%) and diarrhea (43%) [ 10 ].[omicsonline.org]
  • A typical presentation is of colicky abdominal pain, diarrhea and nausea. These non-specific symptoms may result in a delayed diagnosis. Chronic mesenteric vein thrombosis patients typically will not experience pain.[angiologist.com]
  • In the present case, nausea appeared 4 d prior to the development of abdominal pain and, might have been a prodromal symptom rather than an indication of hyperemesis gravidarum.[wjgnet.com]
Acute Abdomen
  • This case also serves to remind physicians that there should always be a high level of suspicion of intestinal infarction in patients with an acute abdomen who are in a hypercoagulable state.[ncbi.nlm.nih.gov]
  • Experiences and lessons MVT should be included in the differential diagnosis of a pregnant patient who presents with an acute abdomen.[wjgnet.com]
  • Acute superior mesenteric vein thrombosis presents vaguely as an acute abdomen with gradually worsening diffuse, colicky abdominal pain, associated with distention, and symptoms may have been present for a few days 2,3.[radiopaedia.org]
Abdominal Distension
  • Severe subcontinuous abdominal pain out of proportion to the physical findings and abdominal distension were the major symptoms in both patients.[ncbi.nlm.nih.gov]
  • Case Report A 21-year-old woman, who was a known case of pre-eclampsia, diagnosed to have HELLP syndrome in the postpartum period was referred to our intensive care unit (ICU) with a history of increasing epigastric pain and abdominal distension for 3[joacc.com]
  • Acute occlusion of the portal vein rather than the superior mesenteric vein causes abdominal distension, ascites, and diffuse abdominal tenderness.[ahajournals.org]
Vein Disorder
  • Disorders [ edit ] Thrombosis of the superior mesenteric vein is quite rare, but a significant cause of mesenteric ischemia and can be fatal.[en.wikipedia.org]
  • […] thrombosis, Thrombosis, Mesenteric Venous, Thromboses, Mesenteric Venous, Mesenteric Venous Thromboses, Mesenteric Venous Thrombosis, Venous Thromboses, Mesenteric, Venous Thrombosis, Mesenteric, Thrombosis of mesenteric vein, Thrombosis of mesenteric vein[fpnotebook.com]
Flushing
  • She recovered fully after treatment, which consisted of thrombectomy, flushing with urokinase and intravenous administration of heparin. Papaverine infused for 4 days substantially improved bowel viability.[ncbi.nlm.nih.gov]

Workup

Because of the nonspecific clinical presentation of MVT, the diagnosis may be difficult to attain based on clinical criteria [6]. Furthermore, the differential diagnosis of nonspecific abdominal pain and associated symptoms is quite broad. For this reason, a detailed and comprehensive approach is necessary in order to raise valid clinical suspicion, which is vital for making the diagnosis [4]. Firstly, physicians should obtain a complete patient history, with an emphasis on the course and progression of symptoms, existence of comorbidities and underlying conditions in the patient or within the family that might be responsible for the presenting complaints, and a history of alcohol and medication use [3]. A thorough physical examination, because of its role in excluding certain pathologies, is equally important, but imaging studies are crucial in confirming MVT. Plain radiography of the abdomen is a useful initial method that might detect dilated bowel loops, ileus and in most severe cases, free air within the abdomen and gas in the portal vein [3]. Ultrasonography and magnetic resonance (MR) angiography have also been recommended for the evaluation of mesenteric veins, but contrast-enhanced computed tomography (CT) is the gold standard, with an accuracy of 90% [1] [3] [4] [5]. The thrombus, seen as a focal translucency, is the hallmark of MVT on CT studies, whereas dilation of the veins is also an important finding [1] [3] [4]. Laboratory workup, although very important for the assessment of the overall status of the patient, is of limited diagnostic benefit in the case of MVT, as only leukocytosis, thrombocytosis, and mild elevations of hepatic and pancreatic enzymes can be observed [1] [3]. Thus, the diagnosis of MVT rests on clinical findings and contrast-enhanced CT.

Hypertriglyceridemia
  • Five (9%) patients had diabetes mellitus (DM), 33 (58%) had overweight or obesity, 9 (18%) had hypertriglyceridemia and 10 (19%) had arterial hypertension. Eleven patients (19%) underwent intestinal resection.[ncbi.nlm.nih.gov]
Hyperviscosity
  • It is also believed that splenectomy favors a hyperviscosity state due to thrombocytosis and postoperative leukocytosis since there is no splenic lysis of these cells [ 22 ].[thejh.org]

Treatment

  • The clinical, biological, and morphological aspects as well as the treatment of this morbid association were studied in three patients.[ncbi.nlm.nih.gov]

Prognosis

  • Prognosis is good in this group of patients, with a mortality of only 7%, although bowel ischemia was noted in 21%.[ncbi.nlm.nih.gov]
  • […] variable) absent once infarcted (more common in arterial occlusion) hyperenhancement or target appearance prolonged enhancement pneumatosis intestinalis : due to transmural infarction dilated and fluid-filled lumen other changes ascites Treatment and prognosis[radiopaedia.org]

Etiology

  • In 30-50% of patients with portal thrombosis, no underlying etiology is found. The recent reports of new hereditary clotting defects are contributing to the understanding of this problem, but they only justify a small number of idiopathic cases.[ncbi.nlm.nih.gov]
  • […] diseases), obesity, neoplasias, hematological disturbances (particularly thrombocytopenia and polycythemia vera), soft tissue trauma, previous abdominal surgery, but also liver cirrhosis and stasis of the venous blood flow are some of the most important etiologies[symptoma.com]
  • While mesenteric arterial thrombosis results from arrhythmia and cardiac etiologies, mesenteric venous thrombosis is overwhelmingly associated with hypercoagulable states, stasis and local factors which lead to vessel wall injury [3].[oatext.com]

Epidemiology

  • Pneumatosis Intestinalis Predictive Evaluation Study (PIPES): A multicenter epidemiologic study of the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2013; 75 (1): 15-23[ DOI ][ PubMed ] 2. Galandiuk S, Fazio VW.[colorectalresearch.com]
  • Epidemiology, risk and prognostic factors in mesenteric venous thrombosis. Br J Surg 2008;95:1245-51. 7. Lee SS, Ha HK, Park SH, Choi EK, Kim AY, Kim JC, et al.[jmgims.co.in]
  • ., Svensson, P. and Ekberg, O, “Epidemiology, risk and prognostic factors in mesenteric venous thrombosis,” Br J Surg, 95. 1245-1251. 2008.[pubs.sciepub.com]
  • Summary Epidemiology Prevalence of methylmalonic acidemia has been estimated at 1/48,000 to 1/61,000 in North America, and at 1/26,000 in China (these values may include patients with methylmalonic acidemia with homocystinuria; see this term).[orpha.net]
Sex distribution
Age distribution

Pathophysiology

  • While MVT has been established in hypercoagulable states and local-abdominal processes (splenectomy, pancreatitis, diverticulitis), its incidence and pathophysiology in the setting of laparoscopic bariatric surgery alone is relatively unknown and rarely[sages.org]
  • Clinical Information Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test Multiple causes of inborn errors of cobalamin (cbl; better known as vitamin B12) metabolism have been identified.[mayocliniclabs.com]
  • Home CCC Portal vein thrombosis by, last update April 25, 2019 OVERVIEW thrombus formation in the portal vein /- tributaries (SMV, IMV and splenic vein) PATHOPHYSIOLOGY can be acute or chronic clot can be within liver or external clot can be occluding[lifeinthefastlane.com]
  • Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 118. Cloud A, Dussel JN, Webster-Lake C, Indes J. Mesenteric ischemia. In: Yeo CJ, ed.[medlineplus.gov]

Prevention

  • Despite gastrointestinal bleeding, anticoagulation therapy with heparin had to be performed to prevent bowel infarction.[ncbi.nlm.nih.gov]
  • Although these collaterals are capable of preventing hemorrhagic infarction, it is not adequate to prevent segmental chronic intestinal ischemia that in turn leads to chronic inflammation and scarring of the small intestine musculature [ 1 ].[pubs.sciepub.com]
  • A ‘classic’ dilemma arises in young stable patients who are not deteriorating in whom a question of long-term complication prevention is relevant. A case report and short discussion can be found here.[angiologist.com]
  • In addition, unfractionated heparin should be administered as soon as the diagnosis is made in order to prevent an extension of the thrombosis.[karger.com]

References

Article

  1. Hmoud B, Singal AK, Kamath PS. Mesenteric Venous Thrombosis. J Clin Exp Hepatol. 2014;4(3):257-263.
  2. Cudnik MT, Darbha S, Jones J, Macedo J, Stockton SW, Hiestand BC. The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis. Acad Emerg Med. 2013;20(11):1087-1100.
  3. Singal AK, Kamath PS, Tefferi A. Mesenteric venous thrombosis. Mayo Clin Proc. 2013;88(3):285-294.
  4. Sucandy I, Gabrielsen JD, Petrick AT. Postoperative mesenteric venous thrombosis: Potential complication related to minimal access surgery in a patient with undiagnosed hypercoagulability. North American Journal of Medical Sciences. 2010;2(7):329-332.
  5. Swartz DE, Felix EL. Acute Mesenteric Venous Thrombosis Following Laparoscopic Roux-en-Y Gastric Bypass. JSLS. 2004;8(2):165-169.
  6. Lang SA, Loss M, Wohlgemuth WA, Schlitt HJ. Clinical Management of Acute Portal/Mesenteric Vein Thrombosis. Viszeralmedizin. 2014;30(6):394-400.

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Last updated: 2019-06-28 10:01