Seetha Lakshmanan, MD, Yashvin O. Mangala, MD, Alexander J. Harmatz, MD; Roger Williams Medical Center, Providence, RI
Introduction: Mesenteric venous thrombosis (MVT) is an uncommon cause for acute abdominal pain, accounting for about 1 in 10,000 inpatient admissions and 10% of acute mesenteric ischemia. Primary or idiopathic MVT represents the presence of thrombus without any predisposing factors like hypercoagulable states or local inflammation. We report a case of superior mesenteric vein (SMV) thrombosis in a young female presenting with nonspecific symptoms.
Methods: A 28-year-old healthy female, non-smoker, presented to our facility with acute abdominal pain for 1 day. Her pain was of sudden onset, diffuse, associated with nausea and multiple episodes of watery diarrhea. She did report having dull abdominal discomfort with food intake and 30lbs unintentional weight loss in past 9 months without prior history of altered bowel habits. She was on Progestin-only implant for the past 6 weeks and never used other hormonal contraceptives before that. There was no family history of hematological or thromboembolic disorders, however her sister has irritable bowel syndrome. Physical examination was significant for diffusely tender abdomen without guarding or rebound tenderness. Labs revealed WBC 8000/µL, Hemoglobin 15.1g/dl, Lipase 37U/L with normal liver enzymes. CT Abdomen showed mural thickening of left colon and hypodensity centrally in the SMV. A follow-up MRI Abdomen revealed proximal migration of the previously seen thrombus into portal vein and portal splenic confluence. Esophagogastroduodenoscopy and colonoscopy were found to be unremarkable. An extensive hypercoagulable workup done was negative and she was started on intravenous Heparin. She was later discharged with long-term oral Apixaban in the absence of clear etiology for the thrombus. Discussion: The only likely risk factor for MVT in this young patient is her hormonal contraceptive, however Progestin-only contraceptives are reported to be least associated with hypercoagulable states. There are 2 reported cases of young women with portal venous thrombosis, however they had secondary causes ie. sickle cell disease, smoking and prolonged oral contraceptive use. It is intriguing that our patient did not have such evident risk factors and yet developed the thrombus. In recent times, the increasing use of CT for investigation of abdominal pain has improved early detection, resulting in a significant reduction in mortality rates and the need for surgical intervention in MVT. Though rare, it is important to detect these cases early for better outcomes.
Hypodensity centrally in the Superior Mesenteric Vein (white arrow)
Disclosures: Seetha Lakshmanan indicated no relevant financial relationships. Yashvin Mangala indicated no relevant financial relationships. Alexander Harmatz indicated no relevant financial relationships.