Mesenteric vein thrombosis: a diagnostic and therapeutic challenge

ABSTRACT

Mesenteric vein thrombosis [MVT] is a rare but a potentially lethal form of mesenteric ischemia. Thirteen patients having MVT [7 males and 6 females] were included in this study. Their ages ranged from 30 to 50 years with a mean +/- standard deviation [SD] of [46.15 +/- 5.52]. Nine of these patients [9/13; 69%] had associated hepatopancreatic diseases 4 with hepatocellular carcinoma [HCC] on top of cirrhosis, 3 with cirrhosis and previous splenectomy, one with cirrhosis, and one with pancreatitis. The remaining four patients [4/13; 31%] had associated nonhepatopancreatic disease 2 with deep venous thrombosis [DVT], and 2 with history of contraceptive pill intake. Severe subcontinuous abdominal pain out of proportion to the physical findings [11/13; 84%] and abdominal distention [9/13; 69%] were the major symptoms. Color duplex ultrasound [US] was performed in all patients and was diagnostic for MVT in only 10 patients [10/13; 77%]. In the remaining 3 patients, diagnosis of MVT was established by computed tomography [CT] in 2, and mesenteric angiography in one. Once the diagnosis of acute MVT was confirmed, all patients were anticoagulated with heparin.Signs of peritonitis were the main indication for immediate exploratory laparotomy in the studied cases [8/13; 61.5%]. Minimal small bowel resection with primary anastomosis was performed in 5 patients, minimal small bowel resection with diverting ileostomy in one, extended small bowel resection with primary anastomosis in one, and laparotomy without resection in one. The determination of viability in the marginally perfused bowel was done with clinical assessment. For further evaluation of bowel viability in borderline cases, Doppler US was performed in 4 patients. The 30-day operative mortality was reported in three patients [3/8; 37.5%]. All of them were having liver cirrhosis that was associated with malignancy in one and splenectomy in another. The 30-day mortality in the five non-surgically treated patients was 60% [3/5] that was mostly due to advanced liver malignancy. In conclusion; a high index of suspicion and recognition of high risk factors coupled with a history of non-specific abdominal symptoms should alert clinicians to the possibility of MVT. Early diagnosis using color duplex US or CT and prompt anticoagulation are the mainstay of therapy unless there are signs of peritonitis that necessitate surgical resection of the infarcted bowel. Although a primary anastomosis can be accomplished in most situations, a diverting ileostomy may often be the prudent approach in cases with poor liver function and bad general conditions. During operation, all nonviable bowels should be resected with intent for a second-look laparotomy after 24 hours if there is any question of ongoing ischemia. We recommend using intraoperative Doppler US for detection of the arterial signals in evaluation of the marginally viable bowel