Ganesh Arun, DO, Farhan Ali, DO, Emily Rey, DO, Dayakar Reddy, MD, Mohammad Raza, MD, Kristian Hochberg, MD Arnot Health, Elmira, NY
Introduction: Mesenteric Vein Thrombosis (MVT) is an uncommon cause of mesenteric ischemia accounting for only 5–15% of all mesenteric ischemia cases. MVT risk factors include acquired risk factors such as surgery, malignancy, trauma, local inflammatory processes or inherited risk factors such as thrombophilias. This review examines the increased risk of MVT in patients with sigmoid diverticulitis due to increased inflammation and subsequent predilection for thrombus formation.
Case Description/Methods: A 41 year old gentleman presented with left lower quadrant abdominal pain with multiple episodes of non-bilious, non-bloody emesis. Past medical history includes diabetes and hypertension both which were controlled with metformin and lisinopril. CT Abdomen/Pelvis (Figure 1) was notable for pericolonic fat stranding compatible with diverticulitis as well as non-opacification of inferior mesenteric vein (IMV) branches of the affected region of the sigmoid colon. Vascular Surgery was consulted, and recommended anticoagulation with heparin with eventual conversion to direct oral anticoagulants (DOAC). The patient’s medical regimen during his hospital course consisted primarily of rocephin, metronidazole and 2 days of bowel rest. By day 3, his symptoms improved and was discharged on rivaroxaban for 6 months.
Discussion: CT abdomen alone rarely diagnoses MVT. Imaging in conjunction with signs of abdominal pain or portal hypertension are often required for a quick and accurate diagnosis. Isolated MVT without portal vein thrombosis is only diagnosed with 67% sensitivity. After MVT is confirmed, testing for JAK2 mutation helps to differentiate myeloproliferative neoplasms and has helped supplant the need for bone marrow biopsy.
Treatment consists of early anticoagulation even in the presence of bleeding. Three to six months of anticoagulation for reversible causes is appropriate. This can be extended if a thrombophilia has been identified. Surgery is required for bowel infarction or subsequent peritonitis.
Outcomes are determined by the underlying prothrombotic state, the extent of recurrent thrombosis and the long term sequelae of short bowel syndrome. MVT recurrence occurs most commonly in the first 30 days after presentation. MVT presentation should be clinically correlated and intervened with early anticoagulation to decrease the need to proceed to surgery.
This case highlights the association of MVT and Diverticulitis to expedite early treatment.
Figure: CT of the Abdomen and Pelvis (axial Figure 1 and coronal Figure 2) demonstrated relative hypo density of the branches extending from the inferior mesenteric vein (red arrow) as well as adjacent fat stranding along the course of the vessel, suggestive of thrombosis. There was peri colonic fat stranding (blue arrow) involving the thickened sigmoid colon, compatible with diverticulitis.
Ganesh Arun indicated no relevant financial relationships.
Farhan Ali indicated no relevant financial relationships.
Emily Rey indicated no relevant financial relationships.
Dayakar Reddy indicated no relevant financial relationships.
Mohammad Raza indicated no relevant financial relationships.
Kristian Hochberg indicated no relevant financial relationships.
Ganesh Arun, DO, Farhan Ali, DO, Emily Rey, DO, Dayakar Reddy, MD, Mohammad Raza, MD, Kristian Hochberg, MD. P0152 - Venous Thrombosis Associated With Diverticulitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.