Mesenteric venous thrombosis and small bowel ischemia
Colicky lower abdominal pain and vomiting. Tachycardic with diffuse abdominal tenderness. Raised white cell count.
CT abdomen and pelvis
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Free fluid in the pelvis, around the liver and spleen. A 30 - 40 cm continuous segment of mid small bowel loop is poorly enhancing with loss of the normal mucosal pattern and complete collapse of the distal small bowel. An extensive filling defect is seen in the main portal vein including the tributaries and the superior mesenteric vein with fat stranding in the root of the small bowel mesentery and reactive small volume mesenteric lymph nodes. Moderate burden of uncomplicated sigmoid diverticulosis.
2 case question available
Portomesenteric vein thrombosis (PMVT) is a rare cause of mesenteric and bowel ischemia. It is important to diagnose accurately and in a timely fashion important as mortality is in the order of 20-30%. It may be asymptomatic. Symptoms are more likely with superior mesenteric vein thrombosis than portal venous thrombosis. When present, symptoms are non-specific and include disproportional abdominal pain (commonest symptom), nausea, abdominal distension and in advanced cases, bloody diarrhea, peritonitis and hemodynamic instability. Diagnosis is often delayed due to symptom non-specificity.
This patient was managed conservatively with a course of intravenous antibiotics and therapeutic dose low molecular weight heparin whilst warfarin was loaded. He was discharged and reviewed in the general surgical and hemostasis clinics. A subsequent thrombophilia screen was normal. It was presumed that the thrombosis was triggered by an undiagnosed episode of lower GI tract inflammation such as diverticulitis.
Case published with assistance from Dr Vikas Shah.