SESSION TITLE: Miscellaneous Global Case Reports
SESSION TYPE: Global Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Portomesenteric vein (PMV) thrombosis may be caused by several pro-thrombotic states. It is an uncommon but potentially lethal cause of mesenteric ischemia. Due to its usually subtle presentation, diagnosis may be difficult in the early stage of disease. This condition may also present as acute bowel obstruction.
CASE PRESENTATION: A 79-year-old Brazilian man presented to the Emergency Department complaining of acute onset and progressive, colicky abdominal pain, along with constipation, vomiting and abdominal distension. There was no fever. The only previous relevant comorbidity was a three years earlier transurethral prostate resection. The patient was admitted to the Intensive Care Unit (ICU) for investigation and pain control. Blood tests were nonspecific. Abdominal computerized tomography (CT) scans showed signs of both portal and superior mesenteric vein thrombosis, along with diffuse bowel distension. Abdominal angiography showed normal aortic and mesenteric arterial vessels. Anticoagulant therapy was started and the patient gradually improved during the next few days. A work-up for the patient’s hypercoagulable state revealed both S-protein and antithrombin III deficiency. C-protein level was in the lower normal limit. Further investigation revealed very high levels of both total and free prostate specific antigen (PSA). The patient was discharged from ICU to investigate the probable underlying malignancy.
DISCUSSION: Acute PMV thrombosis is relatively uncommon if compared to acute superior mesenteric artery occlusion. The majority of cases are secondary to an underlying condition, including hypercoagulable states (malignancy, protein C and protein S deficiency, antithrombin III deficiency, hyperhomocysteinemia), abdominal surgery, and sepsis. It often presents without any specific symptoms and signs, which easily delays diagnosis. Therefore, acute abdominal pain, abdominal distension, vomiting, ascitis, portal hypertension, and bowel obstruction must raise the possibility of this condition. As ischemia progresses, eventual necrosis, perforation, sepsis and shock ensue. The diagnosis relies on imaging, such as Doppler ultrasound and CT scans. Judgment of PMV thrombosis duration is very important for treatment, which includes thrombolysis and anticoagulation, as well as surgical and endovascular management. In our patient the diagnosis was confirmed by abdominal CT scans. Our patient improved with a more conservative approach with anticoagulation. As described in literature, an underlying hypercoagulable state was identified.
CONCLUSIONS: PMV thrombosis may have several different clinical presentations, so that both its accurate diagnosis - which includes the search of an underlying disease - and its individualized management are crucial factors in order to improve outcome.
Reference #1: Mesenteric venous thrombosis: clinical and therapeutical approach. Hotoleanu C, Andercou O, Andercou A. Int Angiol. 2008 Dec; 27(6):462-5.
Reference #2: Portal, superior mesenteric and splenic vein thrombosis secondary to hyperhomocysteinemia with pernicious anemia: a case report Prashanth Venkatesh, Nissar Shaikh, Mohammad F Malmstrom, Vajjala R Kumar, Bakr Nour J Med Case Rep. 2014; 8: 286.
Reference #3: Mesenteric Venous Thrombosis: a rare cause of bowel obstruction P. Horta Oliveira, A. Horta Oliveira, Marina Costa, Américo Silva Rev. Port. Cir. no.22 Lisboa Sept. 2012
DISCLOSURE: The following authors have nothing to disclose: Gilberto Franco, Carlos Alves, Pamela Bianchet, Luciano Colognese, Nadim Amui Jr
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