CASE 12424 Published on 03.02.2015

Complete jejunal segmental transection complicating an acute portomesenteric vein thrombosis in a patient with hypercoagulable state.

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Sammy Tawk, MD1, Aline Geara, MD2, Yasser Tohme, MD FEBS3, William Bakhos, MD4

1 Lebanese University, School of Medicine, Beirut, Lebanon.
2 Residency program director, Radiology Department, Rafic Hariri university hospital, Beirut, Lebanon.
3 General Surgery chief resident, General Surgery Department, Rafic Hariri university hospital, Beirut, Lebanon.
4 Residency program director, General Surgery Department, Rafic Hariri university hospital, Beirut, Lebanon.

Rafic Hariri University Hospital, Radiology; Jnah Beirut, Lebanon; Email:alinegeara@yahoo.fr
Patient

44 years, male

Categories
Area of Interest Haematologic, Abdomen, Gastrointestinal tract, Small bowel ; Imaging Technique CT
Clinical History
The patient was a 44-year-old man with acute abdominal pain. The patient was under anticoagulation for hypercoagulable state. First contrast-enhanced abdominal CT showed portomesenteric vein thrombosis with bowel ischemia.
The patient had stronger anticoagulation, however symptoms persistence lead to another abdominal CT.
Imaging Findings
The first abdominal enhanced Multidetector CT scan (MDCT) was performed shortly after the patient experienced symptoms and showed complete thrombosis in the superior mesenteric vein (SMV) (Fig 1), extending to the proximal part of the portal vein (Fig 2), partially occluding it, with thickened, non enhancing jejunal mid portion segment (Fig 3), surrounded by fat stranding and mild free fluid (10 HU).

Another enhanced scan was performed two weeks later, showing partial recanalisation of the portal vein (Fig 4) with persistent thrombosis of the SMV (Fig 5) and a decrease in bowel wall oedema (Fig 6) with resolution of peritoneal fluid.

Symptoms persisted and a third non enhanced (due to acute renal failure) MDCT scan was performed showing distended proximal jejunal loops (60 mm) (fig 7) and a transitional zone of narrowed mid-jejunal bowel segment (Fig 8) and collapsed distal bowels.
Discussion
Mesenteric vein thrombosis (MVT) is a rare condition, mostly resulting from thrombosis of the SMV [1]. There are two forms: the idiopathic form (50%) [2] and the secondary form that is caused by multiple causes (Hematological, inflammatory etc.) [3-9].
Mortality remains high due to delayed diagnosis and management [10]. A rare complication is bowel ischemia, with bowel infarct being a serious complication [11].

Multidetector CT (MDCT) with multiplanar reformats is the best for diagnosis of MVT [10-16]. Findings with MVT and bowel ischemia on MDCT are classified into: mural, vascular and extramural-nonvascular signs.
Circumferential bowel wall thickening (mural sign) is the most common sign in acute mesenteric venous thrombosis [17], being either spontaneously hypodense (oedema) or hyperdense (haemorrhage), more pronounced in venous than in arterial ischemic causes [18], with the first pattern being highly specific of MVT [17, 19]. Stratification of the bowel wall is another mural sign [20, 21].
Identifying a luminal thrombus is a direct vascular sign of MVT. Vein enlargement or atrophy can be found, depending on the course of thrombus formation; the former seen in the acute form and the latter in the chronic form. Venous collaterals are indirect signs of venous thrombosis.
Fluid filled dilated bowel, mesenteric fat oedema and free fluid [18], are extramural-non vascular signs.
Pneumatosis intestinalis, portomesenteric venous gas and free peritoneal air are seen with impending transmural infarction [6, 7, 22, 23].
Management can be done medically [24], by interventional radiology or surgery [25], [26].

Our patient has an inherited hypercoagulable state (HS). Patients with HS are prone to venous rather than arterial thrombosis [27].
Though treated, the patient developed acute (<4 weeks) [24] portomesenteric vein thrombosis with bowel ischemia. Although an anticoagulation regimen using two drugs was initiated, the symptoms did not resolve and a non injected MDCT (acute renal failure) showed small bowel ischemia and obstruction.
Laparotomy was performed, revealing complete segmental jejunal transection.
Venous thrombosis caused by hypercoagulable state affects the small veins and progresses to larger trunk [6] in contrast to venous thrombosis caused by intra-abdominal processes that affect larger branches. Bowel infarct caused by venous thrombosis occurs rarely but more frequently when the small veins are involved [1], as in our case. Rapidly developing thrombosis is more prone to bowel infarct [28] due to lack of time for collateral formation.
Complete transection was probably due to non recanalisation of the venous arcade with absent collaterals.
Differential Diagnosis List
Complete jejunal segmental transection complicating an acute portomesenteric vein thrombosis.
Acute superior mesenteric artery occlusion.
Volvulus of midgut
Bowel ischaemia due to hypotension
Final Diagnosis
Complete jejunal segmental transection complicating an acute portomesenteric vein thrombosis.
Case information
URL: https://www.eurorad.org/case/12424
DOI: 10.1594/EURORAD/CASE.12424
ISSN: 1563-4086