St. Louis University School of Medicine St. Louis, MO, United States
Eugene C. Nwankwo, MD, MS, Soumojit Ghosh, MD, Zarir Ahmed, DO St. Louis University School of Medicine, St. Louis, MO
Introduction: Superior mesenteric vein thrombosis (SMVT) is an uncommon cause of colonic ischemia, as most cases are from non-occlusive etiologies. Given its nonspecific presentation and high morbidity and mortality, a high index of clinical suspicion is required to make a timely diagnosis. Although abdominal pain is a common presenting symptom for colonic ischemia, not all patients present as such. We herein present a case of a 58-year-old male who presented with hematochezia who was subsequently found to have an acute SMVT causing colonic ischemia.
Case Description/Methods: A 58-year-old male presented with 5 days of hematochezia, nausea and vomiting. Past medical history was pertinent for heavy alcohol use, possible cirrhosis, and chronic pancreatitis. He denied any history of gastrointestinal bleeding (GIB). On presentation, patient was tachycardic but otherwise stable. Labs were notable for hgb 6.4, lipase 65, AST 335, ALT 108, lactic acid 4.5. Physical exam was pertinent for a soft, non-tender, non-distended abdomen. Given lab findings, a subsequent CT abdomen and pelvis revealed a SMVT (figure 1). After blood transfusion, vascular surgery was consulted and recommended non-surgical management. Octreotide, pantoprazole, and heparin drip were started with close monitoring of hgb and signs for GIB. After stabilization, colonoscopy revealed a pale mucosa with petechial bleeding, concerning for ischemia. Patient was worked up for hypercoagulable state which was pending.
Discussion: The association of SMVT with colonic ischemia is uncommon, especially one that can lead to GIB. Most cases are from non-occlusive causes such as hypovolemia. However, given its high mortality rate, it is imperative to maintain a broad differential as misdiagnosis will delay treatment. The most common symptom is abdominal pain, however, other symptoms include nausea, vomiting, diarrhea or GIB. Our patient did not demonstrate significant abdominal pain, and therefore, diagnosis required a high clinical suspicion with the utility of imaging to help diagnose an acute SMVT which caused the GIB in setting of colonic ischemia. Treatment is largely conservative with anticoagulation, despite the presence of bleeding, with close observation. If peritoneal signs are present, then surgical intervention becomes paramount to decrease mortality. Patients should undergo workup for hypercoagulability if no other etiologies can explain the cause of an acute SMVT.
Figure: Figure 1. Occlusive thrombus of the superior mesenteric vein with thrombus extending into the superior mesenteric vein to the level of the portal confluence
Disclosures: Eugene Nwankwo indicated no relevant financial relationships. Soumojit Ghosh indicated no relevant financial relationships. Zarir Ahmed indicated no relevant financial relationships.
Eugene C. Nwankwo, MD, MS, Soumojit Ghosh, MD, Zarir Ahmed, DO. P2297 - An Unusual Presenting Symptom of Acute Superior Mesenteric Vein Thrombosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.