Mesenteric vein thrombosis
(Redirected from Mesenteric venous thrombosis)
Background
- Local thrombus formation in mesenteric veins, which impairs venous return of the bowel
- A rare (< 5% of all cases) subset of mesenteric ischemia that has a high rate of mortality approaching 50%.
- Can be associated with concurrent portal vein thrombosis
- Risk factors include intraabdominal inflammation (pancreatitis, IBD) and hypercoagulability (protein C/S deficiency, malignancy).[1]
- A previous history of DVT is reported in approximately 20-40 percent of patients with mesenteric venous thrombosis
Intestinal Ischemic Disorder Types
- Ischemic colitis
- Acute mesenteric ischemia
- Mesenteric venous thrombosis
- Chronic mesenteric ischemia ("intestinal angina")
Clinical Features
Depends on subtype and disease can exist along a continuum.
- Acute- expect typical features such as severe abdominal pain that is out of proportion to exam findings. Rebound and guarding may occur. Time course usually over days.
- Subacute- abdominal pain can be vague and symptoms may be insidious over a period of days to weeks.
- Chronic- patients usually are asymptomatic and thrombosis is usually found on imaging incidentally. Some patients may have post-prandial colicky abdominal pain that resolves.
- Exam may show distended abdomen or positive fecal occult blood
- Rebound and guarding may occur if bowel wall edema progresses to ischemia
Differential Diagnosis
Diffuse Abdominal pain
- Abdominal aortic aneurysm
- Acute gastroenteritis
- Aortoenteric fisulta
- Appendicitis (early)
- Bowel obstruction
- Bowel perforation
- Diabetic ketoacidosis
- Gastroparesis
- Hernia
- Hypercalcemia
- Inflammatory bowel disease
- Mesenteric ischemia
- Pancreatitis
- Peritonitis
- Sickle cell crisis
- Spontaneous bacterial peritonitis
- Volvulus
Evaluation
Workup
- Labs: CBC, CMP, Lipase, UA, HCG(when applicable), Lactate, Coags.
- Imaging
- From the ED standpoint a multiphase contrast CT is the most accurate and timely (Non-contrast, arterial phase, and venous phase).
- Oral contrast can help delineate bowel thickness.
- Magnetic resonance venography is another option if testing is non-diagnostic.
- Doppler ultrasonography can detect thrombosis in larger veins but is less sensitive[2]
Diagnosis
- Mesenteric vein filling defect is diagnostic
- Bowel thickening, bowel hypoattenuation, bowel enhancement, fat-stranding pneumatosis, potential ascites may also be seen[3]
- Labs, other forms of imaging, and physical exam do not have high enough sensitivity to reliably exclude this diagnosis.
Management
Non-Operative
- Anticoagulation is the mainstay of treatment
- Depending on disposition, can utilize unfractionated heparin, LMWH, or DOACs
- Consider if there are no planned operative management
- IVF, electrolyte repletion, and pain control
- Bowel Rest
- Bowel decompression
- Antibiotics
Operative
- Reserved for patients with overt signs of intestinal necrosis or perforation
Disposition
- Consider admission depending on clinical status
See Also
External Links
References
- ↑ Harnik IG, Brandt LJ. Mesenteric venous thrombosis. Vasc Med. 2010 Oct;15(5):407-18. doi: 10.1177/1358863X10379673. PMID: 20926500.
- ↑ Singal AK, Kamath PS, Tefferi A. Mesenteric venous thrombosis. Mayo Clin Proc. 2013 Mar;88(3):285-94. doi: 10.1016/j.mayocp.2013.01.012. Epub 2013 Feb 27. PMID: 23489453.
- ↑ American Journal of Roentgenology. 2009;192: 408-416. 10.2214/AJR.08.1138