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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]
  • In all, a two stage clinical course (initial acute abdominal pain and fever, followed by chronic intestinal obstruction), corresponding to the sequence thrombosis/stricture, was found. x Ray studies showed a regularly contoured intestinal stricture.[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
  • 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]
  • 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]
  • 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]
  • BACKGROUND: Mesenteric venous thrombosis is a rare cause of acute abdominal pain that may be the result of coagulation abnormalities. METHODS: Four consecutive patients with mesenteric venous thrombosis underwent haematological evaluation.[ncbi.nlm.nih.gov]
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]
  • The main manifestations of MVT were abdominal distension and vomiting. The major etiological factors included deficiency in protein C and S, homocysteinemia, and prior abdominal surgery.[ncbi.nlm.nih.gov]
  • 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]
  • 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]
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]
  • Symptoms may include any of the following: Abdominal pain, which may get worse after eating and over time Bloating Constipation Bloody diarrhea Fever Septic shock Lower gastrointestinal bleeding Vomiting and nausea Blood thinners (most commonly heparin[medlineplus.gov]
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]
  • Two days later abdominal distension developed concomitantly with ventilatory distress due to a large retroperitoneal hematoma.[ncbi.nlm.nih.gov]
  • The main manifestations of MVT were abdominal distension and vomiting. The major etiological factors included deficiency in protein C and S, homocysteinemia, and prior abdominal surgery.[ncbi.nlm.nih.gov]
  • Acute occlusion of the portal vein rather than the superior mesenteric vein causes abdominal distension, ascites, and diffuse abdominal tenderness.[circ.ahajournals.org]
  • Initial symptom of all patients was abdominal pain, which was accompanied by the following symptoms: abdominal distension ( n  5), nausea and vomiting ( n  3), and hematemesis ( n  1).[wjes.biomedcentral.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. Copyright 2009 S. Karger AG, Basel.[ncbi.nlm.nih.gov]
  • 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]
  • Duplex US evaluation of mesenteric vessels in acute abdomen. Prospective study on 325 patients. G Chir, 2008; 29 (10): 449–54 PubMed Google Scholar 18. Aschoff, A.J., G. Stuber, B.W. Becker, et al.[link.springer.com]
  • MVT accounts for 1 in 5000 to 15 000 inpatient admissions and 1 in 1000 emergency surgical laparotomies for acute abdomen. 1 The incidence of MVT has increased over the past 40 years, likely as a result of the greater use of abdominal CT. 2 Age at presentation[circ.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, 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]

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.

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]
  • We report two cases of ischaemic jejunal stenosis occurring 4 weeks after successful treatment of portal and mesenteric vein thrombosis.[ncbi.nlm.nih.gov]
  • In addition to early hormonal therapy and immunosuppressant treatment of the primary disease, surgical treatment should be performed as soon as possible if the disease progresses.[ncbi.nlm.nih.gov]
  • LESSONS: If early diagnosis and treatment could be available, anticoagulation alone might be adequate for the treatment of SMVT associated with trauma.[ncbi.nlm.nih.gov]
  • Prompt diagnostic evaluation with computed tomography may reduce potential treatment delay. Underlying malignancy, advanced age, and prolonged symptom duration are predictive of poor outcome.[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]
  • Early anticoagulation in patients with acute SMVT may avoid the grave prognosis observed in patients with arterial thrombosis. Copyright 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • High index of suspicion, detection of risk factors, CT imaging, and timely intervention are essential for better prognosis. The Author(s) 2014. KEYWORDS: management; mesenteric venous thrombosis; risk factors; surgery[ncbi.nlm.nih.gov]
  • A diagnosis of malignant disease in the setting of MVT has poor prognosis, with a 5-year survival of only 25%. MVT can be effectively treated with anticoagulation in the majority of cases.[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

  • Abstract In 30-50% of patients with portal thrombosis, no underlying etiology is found.[ncbi.nlm.nih.gov]
  • OBJECTIVE: Our purpose was to examine the clinical presentation, imaging appearance, etiology, and clinical outcome in patients who had acute thrombosis of the superior mesenteric vein with radiologically occult cause.[ncbi.nlm.nih.gov]
  • The major etiological factors included deficiency in protein C and S, homocysteinemia, and prior abdominal surgery. Computed tomography (CT) findings were helpful in 80% of the patients.[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]
  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Epidemiology, risk and prognostic factors in mesenteric venous thrombosis. Br J Surg. 2008;95(10):1245-51.[ijsurgery.com]
Sex distribution
Age distribution

Pathophysiology

  • 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]
  • […] by , Last updated May 24, 2016 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 or non-occluding isolated thrombus[lifeinthefastlane.com]
  • Two large series demonstrated that chronic MVT accounts for 24% to 40% of total cases of MVT. 3 Risk Factors and Pathophysiology Risk Factors MVT often results from a combination of hypercoagulability, endothelial injury, and stasis, any of which may[circ.ahajournals.org]
  • The exact pathophysiology of acute SMV thrombosis remains unclear.[wjes.biomedcentral.com]

Prevention

  • Despite gastrointestinal bleeding, anticoagulation therapy with heparin had to be performed to prevent bowel infarction.[ncbi.nlm.nih.gov]
  • Sufficient collaterals can prevent acute haemorrhagic infarction, but bowel stenosis due to chronic ischaemia may develop.[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]
  • This will help prevent recurrent thrombosis. Treatment of Acute mesenteric vein thrombosis involves bowel rest, anticoagulation to limit the extension of thrombosis and monitoring for any clinical deterioration.[omicsonline.org]

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: 2018-06-21 21:19