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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01081-2
10.1016/j.ijscr.2024.110300
110300
Case Report
Acute primary mesenteric venous thrombosis: A case report and literature review
Lin Huiyan a1
Lou Yunpeng a1
Sha Ning a
Gu Xiaofeng a
Wang Zhilu a
Liu Tao liu.tao@aliyun.com
b⁎
a Department of Intensive Care Unit, Navy No. 971 Hospital, Qingdao 266071, Shandong Province, China
b Department of Infectious Diseases, Navy No. 971 Hospital, Qingdao 266071, Shandong Province, China
⁎ Corresponding author. liu.tao@aliyun.com
1 These authors contributed equally to this work.

15 9 2024
10 2024
15 9 2024
123 11030010 8 2024
7 9 2024
13 9 2024
© 2024 Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Mesenteric vein thrombosis (MVT) is a pathological condition characterized by the obstruction of blood flow caused by the formation of new thrombi in the mesenteric veins, resulting in the development of intestinal ischemia due to the absence of collateral circulation. The insidious onset, clinical manifestations and lack of specificity of laboratory tests are significant factors that impede the timely diagnosis of MVT in clinical setting.

Case presentation

This article critically examined the pathogenesis, diagnosis and treatment of a 60-year-old male patient with MVT, while also exploring the etiology, clinical manifestations, diagnostic approaches and management advancement with MVT.

Clinical discussion

We determined that CT angiography serves as a pivotal method for early detection of MVT. Proactive anticoagulation strategy utilizing unfractionated heparin or low molecular weight heparin can notably decrease the mortality rate of patients afflicted with MVT and enhance the clinical outcome.

Conclusion

Surgery is generally not endorsed as the preferential therapeutic intervention for mesenteric venous thrombosis, barring patients with concurrent intestinal necrosis or perforation.

Highlights

• CT angiography serves as a pivotal method for early detection of mesenteric vein thrombosis.

• Proactive anticoagulation can decrease the mortality of patients afflicted with MVT.

Keywords

Mesenteric venous thrombosis
Acute mesenteric ischemia
Case report
Diagnosis
Treatment
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pmc1 Introduction

The event of mesenteric venous thrombosis (MVT) represents a predominant contributor to acute mesenteric ischemia (AMI). Nevertheless, venous AMI remains uncommon, with an incidence globally estimated between 5 %–20 % [[1], [2], [3]]. Largely owing to enhanced vascular imaging technology, the detection rate of MVT has escalated, yet diagnosing MVT remains a formidable task for clinicians due to the heterogeneous symptoms of MVT [4]. The present article delineates the case study of a patient diagnosed with acute primary mesenteric venous thrombosis, providing insight into the etiologies, clinical manifestations, diagnostic approaches, and therapeutic advances pertaining to MVT, with the ultimate aim of enhancing clinicians' comprehension and equipping them for the accurate diagnosis and management of MVT. The work has been reported in line with the SCARE criteria [5].

2 Case/case series presentation

A 60-year-old male patient presented with abdominal distention for 5 days and ongoing dull pain in the upper abdomen associated with nausea and vomiting for 1 day. The patient displayed a body mass index (BMI) > 30 kg/m2. His past medical history included biliary pancreatitis, hypertension, coronary heart disease, and permanent atrial fibrillation. Betalox, atorvastatin calcium tablets, and enteric-coated aspirin were taken orally for 5 years. In 2014, he suffered a fracture of his left clavicle due to a car accident, and he recovered well after surgery. His smoking history was extensive and his family history was non-contributory. Laboratory investigations yielded white blood cell count 18.29 × 109/L, percentage of neutrophils 89.2 %, C-reactive protein (CRP) 69.31 mg/L, blood amylase 37.9 U/L, and urine amylase 1094 U/L. Abdominal ultrasonography demonstrated moderate fatty liver, gallstones, and an enlarged pancreas. Abdominal computed tomography depicted gallstones, edema and thickening of the mesentery and part of the bowel wall, surrounding exudative changes, and a small quantity of ascites (Fig. 1). The patient was hospitalized in the hepatological surgery department with a tentative diagnosis of acute pancreatitis. The therapeutic management involved fasting, gastrointestinal decompression, proton pump inhibitor to inhibit gastric acid secretion, somatostatin to suppress glandular secretion, ulinastatin for anti-inflammatory action, prevention of infection, and replenishment of circulating blood volume. While the patient's abdominal pain showed minor improvement, the imaging indicators tended to become more severe (Fig. 2).Fig. 1 Abdominal CT findings on admission. (A) a full gallbladder and gallstones, (B) a small amount of ascites, (C) edema and thickening of the mesentery and part of the bowel wall.

Fig. 1

Fig. 2 Abdominal CT findings at 24 h after symptomatic treatment. (A) shows bilateral lower lung exudation and segmental atelectasis. (B) and (C) show the ascites increased, and edema in the mesenteric area aggravated.

Fig. 2

Subsequent to 20 h of admission, the patient presented with an abrupt onset of palpitations and chest discomfort, possessing a heart rate between 150 and 180 beats per minute. Electrocardiography unveiled atrial fibrillation. Despite intravenous administration of amiodarone, it proved ineffective, necessitating the patient's transfer to the intensive care unit (ICU). The patient's core temperature was 36.2 °C, with consciousness persistently preserved but responsiveness impaired. The entire physique exhibited clammy, chilling characteristics with ecchymosis surrounding the umbilicus and both lower extremities, and bowel sounds markedly weakened. Arterial blood gas analysis revealed pH 7.49, partial pressure of oxygen (PO2) 67 mmHg, partial pressure of carbon dioxide (PCO2) 20 mmHg, base excess (BE) -6.7 mmol/L, and lactic acid (Lac) 3.5 mmol/L. Laboratory tests ensured preservation of liver function and electrolyte balance, yet oliguria was evident, together with an elevated serum creatinine from 153 to 206 μmol/L, and a D-dimer heightened to 1.5 times the basal level. The patient was in a state of shock, with acute kidney injury (AKI), respiratory alkalosis, metabolic acidosis, and hyperlactatemia. Prominence of mesenteric vascular disease and abdominal infection could not be dismissed. The immediate therapeutic regimen included anticoagulation with low molecular weight heparin (LMWH), anti-infection with cefoperazone/sulbactam (Sulperazone®) combined with ornidazole, fluid replacement, and maintenance of mean arterial pressure ≥ 80 mmHg. However, the patient's condition rapidly deteriorated, with progressive decline in oxygen saturation accompanied by anuria, declining blood pressure, and intensification of acidosis. Mechanical ventilation with endotracheal intubation, continuous renal replacement therapy (CRRT), and norepinephrine were utilized to elevate blood pressure 24 h post-transfer to ICU. Following a period of relatively stable vital signs, a contrast-enhanced computed tomography scan of the abdomen detected thrombosis in the superior mesenteric vein and portal vein, along with distinct pancreatic structures devoid of peripancreatic exudation (Fig. 3). Ultrasonography of the abdomen revealed grossly dilated bowel tubes (Fig. 4).Fig. 3 Enhanced CT scan of the abdomen. (A) shows the portal vein thrombosis. (B) shows the uperior mesenteric venous thrombosis.

Fig. 3

Fig. 4 Ultrasonography of the abdomen revealed markedly dilated bowel tubes.

Fig. 4

Invasive hemodynamic monitoring and echocardiography were conducted to evaluate the patient's hemodynamic status. The findings demonstrated a profound reduction in cardiac index (CI) accompanied by hypotension, whereas the systemic vascular resistance index (SVRI), global end-diastolic volume index (GEDVI), and extravascular lung water index (EVLWI) exhibited normal findings. The patient was discerned to have sepsis-associated myocardial depression secondary to abdominal infection; hence, levosimendan was administered to augment myocardial contractility. After 1 week of nonoperative management, the patient's condition ameliorated, and the hemodynamic parameters progressively stabilized. The slides of the re-examination of abdominal CT enhanced images are depicted in Fig. 5.Fig. 5 The results of re-examination of abdominal CT enhanced scan. (A) shows the portal vein thrombosis and blood flow around the thrombus. (B) and (C) show the superior mesenteric venous thrombosis.

Fig. 5

On the 15th day post-admission to the Intensive Care Unit (ICU), the patient's renal functionality improved and continuous renal replacement therapy (CRRT) was ceased. Tracheal intubation was phased out on day 17. Norepinephrine administration was ceased on day 19. On day 20 (28 days post-onset), the patient was transitioned from the ICU to the general ward for specialized care. He was discharged with a full recovery following a period of 7 months of continual treatment.

3 Discussion

The manifestation of MVT is infrequent in clinical practice. As a result of its subtle onset and deficiency of distinctive symptoms, signs, and laboratory data, the rate of misdiagnosis is relatively elevated. The superior mesenteric vein (SMV) stands as the most susceptible site. A systematic review of the literature spanning from 1966 to 2002 revealed that MVT accounted for <3 % of subjects presenting with AMI [6]. The etiologies of MVT are primarily classified into three categories: primary, secondary and idiopathic [4]. Congenital or acquired coagulation disorders constitute the leading causes of secondary MVT, encompassing antithrombin-III (AT-III), protein-C and protein-S deficiency, hyperhomocysteinemia, activated protein-C resistance and lupus associated coagulation disorders. Obesity (BMI > 30 kg/m2), diabetes, tobacco use and thrombophilia are independent risk factors for primary MVT [7,8]. This patient presents a heightened risk for primary thrombotic disorder due to his BMI > 30 kg/m2 and his extensive history of smoking, coronary artery disease, and atrial fibrillation. The clinical manifestations of MVT lack specificity. These manifestations differ due to the location and duration of the thrombosis, the extent of blood vessels involved, and the degree of intestinal ischemia. Early on, ischemia is confined to the mucosa, and the primary clinical presentations include abdominal pain and diarrhea, with or without nausea and vomiting. As ischemia advances to the full thickness of the intestine, manifestations such as melena, hematemesis, hematochezia and even intestinal perforation and peritonitis may arise. Acute MVT can involve the ileum (64 %–83 %), jejunum (50 %–81 %), colon (14 %), and duodenum (4 %–8 %), accompanied by significant abdominal pain. Chronic MVT is frequently associated with moderate abdominal pain and minimal colon involvement due to the formation of multiple collateral circulations [[9], [10], [11]]. In our patient, the thrombus exhibited an acute onset, with occlusion of the vessel within a brief period of time and a drastic reduction in blood flow. Consequently, his abdominal pain manifested early and tended to escalate significantly, along with accompanying symptoms such as nausea and vomiting.

Underscoring similar clinical presentations, laboratory testing of MVT lacks specificity, rendering it challenging to determine accurately within a brief timeframe via conventional lab assessments. Hyperlactacidemia and metabolic acidosis frequently manifest in the advanced stages of intestinal ischemia or when accompanied by abdominal infection. There is no discernible serum biomarker to forecast the onset of intestinal necrosis [12,13]. Spiral CT angiography is the most pragmatic and dependable method for the ascertainment of MVT, offering a sensitivity exceeding 90 % [11,14,15]. Selective mesenteric angiography serves as the criterion standard for confirming MVT, although it is challenging to execute and has limited clinical utility. Color Doppler ultrasonography is also an auxiliary diagnostic tool for MVT, displaying real-time blood flow patterns of the mesenteric vasculature. However, ultrasonographic diagnostics necessitate higher clinician standards and the complexity of gastrointestinal sound adds another layer of complexity, making its utilization quite arduous for clinicians. Given the patient's significant intestinal gas, which interfered with the acquisition of abdominal ultrasound images and negated diagnosis via ultrasonography, labs showed elevated inflammatory markers and amylase, none of which were diagnostic specific. Hence, spiral CT angiography emerges as the sole feasible method for early definitive diagnosis. Indeed, we obtained favorable outcomes through confirmation of diagnosis via spiral CT angiography within 72 h of admission, employing it as a diagnostic aid for efficacy evaluation.

The management of MVT hinges upon the phase of the disease and the condition of the individual [16,17]. Prompt initiation of unfractionated heparin (UFH) or low molecular weight heparin (LMWH) anticoagulation can appreciably diminish the mortality and recurrence rate post-clinical recovery [18]. Surgery is not initially pursued for the treatment of mesenteric venous thrombosis. Generally speaking, it is carried out exclusively in individuals with partial or total intestinal necrosis and intestinal perforation [13]. Nonetheless, differing from mesenteric artery ischemia, the delineation of intestinal necrosis induced by mesenteric vein ischemia is commonly obscure, and the extent of resection might be challenging to ascertain during the operation. In this case, the severity of the intestinal ischemia was not pronounced, and CTA angiography depicted that the SMV and portal vein were incompletely obstructed. Concurrently, through monitoring intra-abdominal pressure and abdominal circumference, we discerned that the patient's bowels were not entirely necrotic and the abdominal symptoms were not deteriorating. Additionally, we had no prior surgical expertise with similar pathologies, and the risks and advantages of an early surgery could not be estimated. For these reasons, we opted for a nonsurgical treatment strategy with vigorous anticoagulation and obtained favorable clinical outcomes.

4 Conclusion

In summation, MVT exhibits an elusive onset. Absence of distinctive clinical signs and specialized ancillary tests complicate the diagnosis. Although the incidence of MVT is not substantial, its substantial complication rate and mortality warrant our intense vigilance. Timely diagnosis, vigorous anticoagulation, and prompt surgical intervention are imperative in the management of MVT, which also serves as a vital strategy to secure optimal clinical outcomes for patients.

Ethical approval

In this study, the ethics approval was obtained from the Medical Research and Ethics Committees at Navy 971 hospital in Qingdao, Shandong, China. The photograph and publication of this case have obtained written consent from the patient's legal guardian.

Funding

This work was supported by the Military Health and Epidemic Prevention and Protection Special Project (grant number: Houwei(2021) No. 208 ).

Author contribution

Tao Liu and Huiyan Lin,and Yunpeng Lou design the paper and writing the paper, Ning Sha, Xiaofeng Gu, Zhilu Wang contribution data collection, data analysis or interpretation.

Guarantor

Tao Liu.

Research registration number

No.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

We thank the patient, the nurses and clinical staffs who has provided care for the patient.

Consent for publication

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
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