CASE 17430 Published on 08.10.2021

Extensive thrombosis of portal venous system in patient with COVID-19 pneumonia

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Dr Jayakrishnan R, Dr Rita Thomas Cheenath, Dr Harisankar S

Department of Radiodiagnosis, Govt. T.D Medical College, Alappuzha, India

Patient

64 years, male

Categories
Area of Interest Small bowel, Vascular ; Imaging Technique CT-Angiography
Clinical History

A 64-year-old male with history of diabetes mellitus, dyslipidemia, coronary artery disease admitted with low grade fever, breathing difficulties and positive RT-PCR for COVID-19 infection from throat swab. The patient developed complaint of diffuse abdominal pain 8 days after admission.

Imaging Findings

CT of abdomen and pelvis was done with intravenous contrast and showed extensive thrombosis of the portal, superior mesenteric and splenic veins. Long segment thickening of the small bowel with submucosal edema and hypoenhancement was noted. Marked mesenteric congestion noted along the course of the thrombosed superior mesenteric vein. Non-enhancing low attenuation wedge shaped areas noted in the spleen representing infarction. Wedge shaped areas of hyperenhancement in liver with homogeneous attenuation in portal venous phase was noted, suggestive of transient hepatic attenuation differences due to portal vein thrombosis.

Discussion

Background

Apart from the typical symptoms of fever, dry cough and myalgia, gastrointestinal symptoms in the form of abdominal pain, diarrhoea have been reported in various stages and severity of COVID-19 infection. Derangements in haemostasis occurring in patients with COVID-19 infection have been termed COVID-19 associated coagulopathy (CAC)[1]. The pro-coagulant state occurs as the result of a macrophage and endothelial cell mediated process culminating in the acceleration of fibrin synthesis and downregulation of fibrin degradation [2,3].

Clinical perspective

In the critically ill patients, development of acute onset abdominal pain and tenderness on palpation warrants suspicion of mesenteric vascular thrombosis [4].

Imaging perspective

 Abdominal radiographs and non-contrast CT may show focal dilatation of bowel loops. Pneumatosis, pneumoperitoneum and gas in the veins points to the onset of bowel infarction. Hyperattenuating thickened bowel can be seen in the setting of mesenteric venous thrombosis due to submucosal haemorrhage. On CT, thick-walled, edematous and dilated bowel should raise suspicion of acute mesenteric ischemia [4,5]. Further evaluation with contrast enhanced CT is essential for early diagnosis and prevention of bowel necrosis. CT findings in mesenteric ischemic of venous origin include partial or complete filling defect in the vein, increase in the calibre of the vein, engorgement of the mesenteric veins and increased attenuation of mesentery. Presence of intramural gas, pneumoperitoneum and large amounts of intraperitoneal fluid are signs pointing to bowel infarction[6].

Extensive thrombosis of the portal venous system may result in transient hepatic attenuation differences in contrast enhanced CT. Hepatic infarctions are not usually encountered owing to the perfusion from the hepatic artery. Extensive thrombosis of the splenic vein can result in focal splenic infarctions. Hepatic and splenic infarctions will appear as wedge-shaped non-enhancing areas in the portal venous phase of contrast-enhanced CT [7].

Outcome

Early diagnosis by identifying the red flag signs on plain radiography and further evaluation with contrast enhanced CT was helpful in timely initiation of anticoagulant therapy and preventing massive bowel necrosis.

Teaching points

Contrast enhanced CT protocol with non-enhanced, arterial and portal venous phases is essential in the diagnosis of vascular thrombosis and resultant complications. Non-enhanced phase helps in identification of intramural haemorrhage associated with venous infarction of the bowel.

Written informed consent for publication has been obtained.

Differential Diagnosis List
COVID-19 pneumonia with portal, superior mesenteric and splenic vein thrombosis
Gastroenteritis
Crohn’s disease
Final Diagnosis
COVID-19 pneumonia with portal, superior mesenteric and splenic vein thrombosis
Case information
URL: https://www.eurorad.org/case/17430
DOI: 10.35100/eurorad/case.17430
ISSN: 1563-4086
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