CASE 12424 Published on 03.02.2015

Complete jejunal segmental transection complicating an acute portomesenteric vein thrombosis in a patient with hypercoagulable state.

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Sammy Tawk, MD¹, Aline Geara, MD², Yasser Tohme, MD FEBS³, William Bakhos, MD⁴

¹ Lebanese University, School of Medicine, Beirut, Lebanon.
² Residency program director, Radiology Department, Rafic Hariri university hospital, Beirut, Lebanon.
³ General Surgery chief resident, General Surgery Department, Rafic Hariri university hospital, Beirut, Lebanon.
⁴ Residency program director, General Surgery Department, Rafic Hariri university hospital, Beirut, Lebanon.

Rafic Hariri University Hospital, Radiology; Jnah Beirut, Lebanon; Email:alinegeara@yahoo.fr

Patient

44 years, male

Categories

Area of Interest Haematologic, Abdomen, Gastrointestinal tract, Small bowel ; Imaging Technique CT

Procedure Contrast agent-intravenous, Diagnostic procedure, Computer Applications-Detection, diagnosis ; Special Focus Haematologic diseases, Embolism / Thrombosis, Haemodynamics / Flow dynamics, Ischaemia / Infarction, Obstruction / Occlusion ;

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Clinical History

The patient was a 44-year-old man with acute abdominal pain. The patient was under anticoagulation for hypercoagulable state. First contrast-enhanced abdominal CT showed portomesenteric vein thrombosis with bowel ischemia.
The patient had stronger anticoagulation, however symptoms persistence lead to another abdominal CT.

Imaging Findings

The first abdominal enhanced Multidetector CT scan (MDCT) was performed shortly after the patient experienced symptoms and showed complete thrombosis in the superior mesenteric vein (SMV) (Fig 1), extending to the proximal part of the portal vein (Fig 2), partially occluding it, with thickened, non enhancing jejunal mid portion segment (Fig 3), surrounded by fat stranding and mild free fluid (10 HU).

Another enhanced scan was performed two weeks later, showing partial recanalisation of the portal vein (Fig 4) with persistent thrombosis of the SMV (Fig 5) and a decrease in bowel wall oedema (Fig 6) with resolution of peritoneal fluid.

Symptoms persisted and a third non enhanced (due to acute renal failure) MDCT scan was performed showing distended proximal jejunal loops (60 mm) (fig 7) and a transitional zone of narrowed mid-jejunal bowel segment (Fig 8) and collapsed distal bowels.

Discussion

Mesenteric vein thrombosis (MVT) is a rare condition, mostly resulting from thrombosis of the SMV [1]. There are two forms: the idiopathic form (50%) [2] and the secondary form that is caused by multiple causes (Hematological, inflammatory etc.) [3-9].
Mortality remains high due to delayed diagnosis and management [10]. A rare complication is bowel ischemia, with bowel infarct being a serious complication [11].

Multidetector CT (MDCT) with multiplanar reformats is the best for diagnosis of MVT [10-16]. Findings with MVT and bowel ischemia on MDCT are classified into: mural, vascular and extramural-nonvascular signs.
Circumferential bowel wall thickening (mural sign) is the most common sign in acute mesenteric venous thrombosis [17], being either spontaneously hypodense (oedema) or hyperdense (haemorrhage), more pronounced in venous than in arterial ischemic causes [18], with the first pattern being highly specific of MVT [17, 19]. Stratification of the bowel wall is another mural sign [20, 21].
Identifying a luminal thrombus is a direct vascular sign of MVT. Vein enlargement or atrophy can be found, depending on the course of thrombus formation; the former seen in the acute form and the latter in the chronic form. Venous collaterals are indirect signs of venous thrombosis.
Fluid filled dilated bowel, mesenteric fat oedema and free fluid [18], are extramural-non vascular signs.
Pneumatosis intestinalis, portomesenteric venous gas and free peritoneal air are seen with impending transmural infarction [6, 7, 22, 23].
Management can be done medically [24], by interventional radiology or surgery [25], [26].

Our patient has an inherited hypercoagulable state (HS). Patients with HS are prone to venous rather than arterial thrombosis [27].
Though treated, the patient developed acute (<4 weeks) [24] portomesenteric vein thrombosis with bowel ischemia. Although an anticoagulation regimen using two drugs was initiated, the symptoms did not resolve and a non injected MDCT (acute renal failure) showed small bowel ischemia and obstruction.
Laparotomy was performed, revealing complete segmental jejunal transection.
Venous thrombosis caused by hypercoagulable state affects the small veins and progresses to larger trunk [6] in contrast to venous thrombosis caused by intra-abdominal processes that affect larger branches. Bowel infarct caused by venous thrombosis occurs rarely but more frequently when the small veins are involved [1], as in our case. Rapidly developing thrombosis is more prone to bowel infarct [28] due to lack of time for collateral formation.
Complete transection was probably due to non recanalisation of the venous arcade with absent collaterals.

Differential Diagnosis List

Complete jejunal segmental transection complicating an acute portomesenteric vein thrombosis.

Acute superior mesenteric artery occlusion.

Volvulus of midgut

Bowel ischaemia due to hypotension

Final Diagnosis

Complete jejunal segmental transection complicating an acute portomesenteric vein thrombosis.

References

[1] Johnson CC, Baggenstoss AH (1949) Mesenteric vascular occlusion; study of 99 cases of occlusion of veins. Proc Staff Meet Mayo Clinic 24(25):628–636. (PMID: 15399067)

[2] Galukande M, Fualal J, Nyangoma E (2009) Mesenteric venous thrombosis in Uganda: a retrospective study of five cases. Afr Health Sci 9(4):284–9 (PMID: 21503183)

[3] Grendell JM, Ockner RK (1982) Mesenteric venous thrombosis. Gastroenterology 82: 358-72 (PMID: 7033036)

[4] Valla D, Casadevall N, Huisse MG, Tulliez M, Grange JD, Muller 0, et al (1988) Etiology of portal venous thrombosis in adults. A prospective evaluation of primary myeloproliferative disorders. Gastroenterology 94: 1063-9 (PMID: 3345875)

[5] Marzelle J (1990) Thromboses portale et mesenterique. Etiologie, manifestations cliniques et traitement. Ann Gastroenterol Hepatol 26: 51-60 (PMID: 2189354)

[6] S. Kumar, M. G. Sarr, and P. S. Kamath (2001) Mesenteric venous thrombosis. The New England Journal of Medicine vol. 345, no. 23, pp. 1683–1688 (PMID: 11759648)

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[8] D. Goitein, I. Matter, A. Raziel et al (2013) Portomesenteric thrombosis following laparoscopic bariatric surgery: incidence, patterns of clinical presentation, and etiology in a bariatric patient population. JAMA Surgery vol. 148, no. 4, pp. 340–346 (PMID: 23715896)

[9] S. Acosta, A. Alhadad, P. Svensson, and O. Ekberg (2008) Epidemiology, risk and prognostic factors in mesenteric venous thrombosis. British Journal of Surgery vol. 95, no. 10, pp. 1245 (PMID: 18720461)

[10] Rhee RY, Gloviczki P (1997) Mesenteric venous thrombosis. Surg Clin North Am 77:327–338 (PMID: 9146716)

[11] Hideki Katagiri, Shozo Kunizaki, Mayu Shimaguchi, Yasuo Yoshinaga, Yukihiro Kanda, Alan T. Lefor and Ken Mizokami (2013) Superior Mesenteric Venous Thrombosis after Laparoscopic Exploration for Small Bowel Obstruction. Case Reports in Surgery Article ID 952383, 3 pages (PMID: 24455391)

[12] Harward TR, Green D, Bergan JJ, Rizzo RJ, Yao JS (1989) Mesenteric venous thrombosis. J Vasc Surg 9:328–333 (PMID: 2918628)

[13] Segatto E, Mortelé KJ, Ji H, Wiesner W, Ros PR (2003) Acute small bowel ischemia: CT imaging findings. Semin Ultrasound CT MR 24:364–376 (PMID: 14620718)

[14] Horton KM, Fishman EK (2009) Multidetector CT angiography in the diagnosis of mesenteric ischemia. Radiol Clin North Am 45:275–288 (PMID: 17502217)

[15] Kirkpatrick ID, Kroeker MA, Greenberg HM (2003) Biphasic CT with mesenteric CT angiography in the evaluation of acute mesenteric ischemia: initial experience. Radiology 229:91–98 (PMID: 12944600)

[16] Bradbury MS, Kavanagh PV, Bechtold RE, et al (2002) Mesenteric venous thrombosis: diagnosis and noninvasive imaging. RadioGraphics 22: 527–541 (PMID: 12006685)

[17] Harward TR, Green D, Bergan JJ, Rizzo RJ, Yao JS (1989) Mesenteric venous thrombosis. J Vasc Surg 9:328–333 (PMID: 2918628)

[18] Lee SS, Ha HK, Park SH, et al. (2008) Usefulness of com¬puted tomography in differentiating transmural infarction from nontransmural ischemia of the small intestine in patients with acute mesenteric venous thrombosis. J Comput Assist Tomogr 32(5): 730–737. (PMID: 18830102)

[19] Whitehead R (1976) The pathology of ischemia of the intestines. Pathol Annu 11:1–52 (PMID: 794801)

[20] Chou CK, Mak CW, Tzeng WS, Chang JM. (2004) CT of small bowel ischemia. Abdom Imaging 29(1): 18–22 (PMID: 15160748)

[21] Wittenberg J, Harisinghani MG, Jhaveri K, Varghese J, Mueller PR (2002) Algorithmic approach to CT diagnosis of the abnormal bowel wall. RadioGraphics 22(5):1093–1107; discussion 1107–1109 (PMID: 12235339)

[22] Rha SE, Ha HK, Lee SH, et al (2000) CT and MR imaging findings of bowel ischemia from various primary causes. RadioGraphics 20:29–42 (PMID: 10682769)

[23] Wiesner W, Mortelé KJ, Glickman JN, Ji H, Ros PR (2001) Pneumatosis intestinalis and portomesenteric venous gas in intestinal ischemia: correlation of CT findings with severity of ischemia and clinical outcome. AJR Am J Roentgenol 177(6):1319–1323 (PMID: 11717075)

[24] Sebastià C, Quiroga S, Espin E, Boyé R, Alvarez- Castells A, Armengol M (2000) Portomesenteric vein gas: pathologic mechanisms, CT findings, and prognosis. RadioGraphics 20(5):1213-24; discussion 1224-6 (PMID: 10992012)

[25] Hassan HA, Raufman JP (1999) Mesenteric venous thrombosis. South Med J 92:558–562 (PMID: 10372847)

[26] Poplausky MR, Kaufman JA, Geller SC, Wattman AC (1996) Mesenteric venous thrombosis treated with urokinase via the superior mesenteric artery. Gastroenterology 110:1633–1635 (PMID: 8613072)

[27] Rivitz SM, Geller SC, Hahn C, Waltman AC (1995) Treatment of acute mesenteric venous thrombosis with transjugular intramesenteric urokinase infusion. J Vasc Interv Radiol 6(2):219-23; discussion 224-8 (PMID: 7787355)

[28] Duran R, Denys AL, Letovanec I, Meuli RA, Schmidt S (2012) Multidetector CT Features of Mesenteric Vein Thrombosis. RadioGraphics 1;32(5):1503–22 (PMID: 22977032)

Case information

URL:	https://eurorad.org/case/12424
DOI:	10.1594/EURORAD/CASE.12424
ISSN:	1563-4086

Figure 1