Rajesh Essrani, MD1, Shehriyar Mehershahi, MD2, Rajesh Essrani, MD2, Shri Jai Kirshan Ravi, MD3, Asif Mehmood, MD1
1Geisinger Medical Center, Danville, PA; 2Bronx Lebanon Hospital Center, Bronx, NY; 3Guthrie Robert Packer Hospital, Sayre, PA
Introduction: Acute pancreatitis can result in many vascular problems such as splanchnic vein thrombosis (splenic, portal, and/or superior mesenteric veins) and pseudoaneurysm. Thrombosis of the superior mesenteric vein (SMV) without simultaneous thrombosis of the splenic or portal vein is very rare.
Case Description/Methods: A 40-year-old man with a past medical history of tobacco abuse admitted with complaints of sudden onset of epigastric pain with radiation to back associated with nausea and vomiting since last two days. On exam, blood pressure 156/76, respiratory rate 13, saturation 91% on room air, and pulse 101. The abdomen was soft but tender in the epigastric area, no right upper quadrant tenderness, and bowel sounds decreased in all quadrant. Blood work showed hemoglobin 15.1 g/dL, hematocrit 45.2 %, WBC 17.04 K/uL (80% neutrophils), platelets 600 K/uL, AST 24 U/L , ALT 22 U/L, alkaline phosphatase 144 U/L, lactate 1.2 mmol/L, triglyceride level 86 mg/dL, LDL 160 mg/dL, calcium 9.1 mg/dL, BUN 30 mg/dL, creatinine 1.3 mg/dL, sodium 139 mmol/L, and lipase 600 U/L. CT abdomen/pelvis showed pancreatitis, normal biliary duct, and an absence of opacification of the SMV. He denied any personal or family history of coagulopathy and denied alcohol intake. He was treated with pain medications and lactated Ringer's solution at 5 mL/kg per hour. Hematology recommended low-molecular-weight heparin 1mg/kg twice a day and Coumadin. His conditions improved in 3 days, and he was discharged home with Coumadin to complete three months of treatment.
Discussion: Mesenteric venous thrombosis (MVT) is usually caused by a local intra-abdominal inflammatory process (e.g., pancreatitis), local trauma (e.g., splenectomy), heritable, and acquired thrombophilia. Most cases of pancreatitis are mild and self-limiting, but some cases may develop complications such as MVT which is an emergent condition. It is rare to find an isolated SMV thrombosis without involving splenic or portal vein in acute pancreatitis as thrombosis usually develops due to vascular stasis in the setting of local infection. SMV thrombosis can present acutely, subacutely, or more chronically. CT of the abdomen is used for the diagnosis. The treatment of SMV thrombosis (acute and subacute) is predominantly conservative, consisting of systemic anticoagulation, bowel rest, and serial observation for any signs of clinical deterioration. Surgical exploration is limited to those patients with definite signs of bowel infarction.
Citation: Rajesh Essrani, MD; Shehriyar Mehershahi, MD; Rajesh Essrani, MD; Shri Jai Kirshan Ravi, MD; Asif Mehmood, MD. P0949 - ISOLATED THROMBOSIS OF THE SUPERIOR MESENTERIC VEIN. Program No. P0949. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.