Mount Sinai Beth Israel Medical Center New York, NY, United States
Gres Karim, MD1, Michelle Shah, DO1, Sanjana Luther, MD2, Ilan Weisberg, MD, MSc2 1Mount Sinai Beth Israel Medical Center, New York, NY; 2Mount Sinai Morningside and Mount Sinai West/Mount Sinai Beth Israel Medical Center, New York, NY
Introduction: Acute pancreatitis is the most frequent cause of gastrointestinal-related hospital admissions in the United States, resulting in greater than 200,000 annual admissions. Porto-spleno-mesenteric venous thrombosis (PSMVT) is a rare condition, with high morbidity and mortality, that may develop as a result of pancreatitis and its presentation is highly variable and nonspecific. Rarely present in the absence of pancreatic necrosis, it is thought to be secondary to local extension of inflammation and obstruction of blood flow secondary to proteolytic enzyme activity. Here we report a rare case of PSMVT secondary to acute pancreatitis without necrosis, successfully managed with anticoagulation.
Case Description/Methods: A 32-year-old man presented with ten days of left upper quadrant (LUQ) abdominal pain radiating to his back, with associated anorexia and weight loss over an 8-week period. Medical history included idiopathic pericarditis, nephrolithiasis, and gangrenous cholecystitis with subsequent cholecystectomy. Alcohol use and cigarette smoking were reported. Physical exam was significant for left flank and LUQ tenderness. Laboratory studies revealed a WBC of 12.8 K/uL. Lipase, liver tests, and INR were normal. CT abdomen was suggestive of pancreatitis without necrosis and revealed superior mesenteric venous thrombosis with thrombophlebitis. MRI Abdomen for further vasculature evaluation found superior mesenteric and portal venous thrombophlebitis with occlusive thrombus visualized throughout the SMV, splenic vein, as well as intra and extrahepatic portal veins. Mesenteric fat stranding and reactive lymph nodes were found. The pancreas was normal without lesion or ductal dilatation. Hypercoagulable workup was unrevealing. He was treated with heparin and discharged home on Eliquis. Repeat CT Venography after 3 months of anticoagulation demonstrated marked improvement.
Discussion: This case demonstrates that PSMVT may rarely develop secondary to acute, non-necrotizing pancreatitis. PSMVT usually only involves the splenic vein and develops in more than 50% of patients with necrotizing acute pancreatitis. In this case, there was complete vessel involvement without necrotizing pancreatitis. Due to the vague presentation of PSMVT early diagnosis is essential to initiate anticoagulation and prevent adverse outcomes, such as subsequent portal hypertension and collateral vessel formation. Given the frequent incidence of pancreatitis, it is important to recognize and effectively treat complications early.
Figure: Image 1: Abdominal MRI Coronal T1 Weighted Post Contrast: Occlusive bland thrombus visualized through the portal vein (red arrow), proximal to mid splenic vein (blue arrow), and throughout the superior mesenteric vein (yellow arrow) and its branches in addition to soft tissue thickening and fat stranding of the superior mesenteric vein. There is also reactive sub-centimeter lymph node enlargement (green arrow).
Disclosures: Gres Karim indicated no relevant financial relationships. Michelle Shah indicated no relevant financial relationships. Sanjana Luther indicated no relevant financial relationships. Ilan Weisberg indicated no relevant financial relationships.
Gres Karim, MD1, Michelle Shah, DO1, Sanjana Luther, MD2, Ilan Weisberg, MD, MSc2. P0041 - A Rare Case of Porto-Spleno-Mesenteric Venous Thrombosis (PSMVT) Secondary to Mild Acute Pancreatitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.