Gastrointestinal
Gastrointest Radiol 1,275-276 (1976)
Radiology ,~ by Springer-Verlag 1976
Idiopathic Inferior Mesenteric Venous Thrombosis Demonstrated by Angiography R o n a l d S. R a n k i n a n d J o h n L. H u s s e y Department of Radiology and Surgery, Center for Health Sciences, University of Wisconsin, Madison, Wisconsin, U.S.A.
Abstract.
I d i o p a t h i c t h r o m b o s i s o f the i n f e r i o r m e s e n t e r i c vein, n o t a s s o c i a t e d w i t h p o r t a l v e i n t h r o m b o s i s , is an u n c o m m o n l y d i a g n o s e d lesion. W e are r e p o r t i n g a c a s e o f i n f e r i o r m e s e n t e r i c v e i n t h r o m b o s i s d i a g n o s e d p r e o p e r a t i v e l y by a n g i o g r a p h y . W e believe this to be the first c a s e in the l i t e r a t u r e o f this p a r t i c u l a r lesion d e m o n s t r a t e d c o n c l u s i v e l y by a n g i o g r a p h y b e f o r e surgery.
Mesenteric venous thrombosis, which does not develo p s e c o n d a r y to a n y c l e a r - c u t a n t e c e d e n t e v e n t ( b o w e l i n f a r c t i o n , v o l v u l u s , t r a u m a , etc.) a n d d o e s n o t p r i m a r ily i n v o l v e the p o r t a l c i r c u l a t i o n , is a d i s t i n c t clinical entity w h i c h has b e e n v a r i o u s l y d e s i g n a t e d as a g n o genic, p r i m a r y , o r s p o n t a n e o u s m e s e n t e r i c v e n o u s t h r o m b o s i s [1, 2, 5]. W e a r e r e p o r t i n g a case o f inferior m e s e n t e r i c v e i n ( I M V ) t h r o m b o s i s w h i c h w a s c o n clusively d e m o n s t r a t e d a n g i o g r a p h i c a l l y o n p r e o p e r a tive a n d f o l l o w - u p studies.
of blood, urine, and sputum were all negative. Her signs and symptoms waxed and waned for several weeks before she evidenced rectal bleeding, which was minor at first and was originally attributed to her hemorrhoids. Proctosigmoidoscopy to 25 cm revealed small amounts of "currant jelly" stool. She developed fresh rectal bleeding but refused a barium enema. Again she underwent proctosigmoidoscopy with negative findings. Therefore, a transfemoral arteriography was performed which showed a distal IMV thrombosis and an area of mucosal congestion in the rectum but no definite bleeding site (Fig. 1). She was treated with one unit of low molecular weight dextran intravenously. Anticoagulants were avoided because of the prolonged bleeding time, elevated prothrombin time, and thrombocytopenia. Uncontrolled bleeding from the arterial puncture site led to exploration of the femoral area and closure of the arterial puncture. Because of increased peritoneal irritation, she. at the same time, underwent exploratory laparotomy. This confirmed the IMV thrombosis but showed no evidence of bowel ischemia. Following surgery, the patient became unmanageably hypertensive and continued to have minor rectal bleeding requiring intermittent transfusion. Proctoscopy was done at the time for increased "currant jelly" bleeding. This did not show a bleeding point to the 20 cm level; and the bowel looked viable, although somewhat dusky at the 8 12 cm level. The same evening, she bled massively from the rectum. Repeat arteriography showed two large arterial bleeding sites about 10 cm from the anus. Bleeding quickly ceased with an intra-arterial vasopressin infusion. The IMV thrombus previously seen had completely resolved (Fig. 2). Several hours after the procedure, she became febrile, leukopenic, and confused. A gram-negative septic shock led to patient's death 4 days later.
Case Report
Discussion
This 47-year-old white female suffered from malignant hypertension and chronic renal failure for over 10 years. She had undergone splenectomy, bilateral nephrectomy, and a renal transplantation several months prior to admission to the hospital. There was no history of gastrointestinal bleeding except from hemorrhoids. The patient's complicated medical history also included episodes of cardiac decompensation, myocardial infarction, and even a successfully treated cardiac arrest. Her admission was prompted by cardiac failure and severe hypertension. Her white blood count was 23,000 mm 3. Cultures
I d i o p a t h i c i n f e r i o r m e s e n t e r i c v e n o u s t h r o m b o s i s is p r o b a b l y a r e l a t i v e l y r a r e c o n d i t i o n a n d it is q u i t e u n u s u a l to m a k e the d i a g n o s i s w h e n the t h r o m b u s i n v o l v e s o n l y a s m a l l v e i n s u c h as the I M V [1, 9]. T h e c l i n i c a l p i c t u r e is o f t e n v a g u e [4, 5], a n d the x - r a y f i n d i n g s a r e u s u a l l y n o t specific, a l t h o u g h s o m e f i n d i n g s o n p l a i n films a n d b a r i u m s t u d i e s h a v e b e e n d e s c r i b e d [2, 4, 6]. A n g i o g r a p h y has b e e n s u g g e s t e d in the diagn o s i s o f m e s e n t e r i c v e n o u s t h r o m b o s i s o n t h e basis o f e x p e r i m e n t a l w o r k [7, 8]. H o w e v e r , a c t u a l d e m o n s t r a t i o n o f t h e l e s i o n by a n g i o g r a p h y m a y be difficult as a r t e r i a l s p a s m t h a t o f t e n f o l l o w s v e n o u s o c c l u s i o n
Key words: I n f e r i o r m e s e n t e r i c vein, t h r o m b o s i s Angiography.
Address reprhTt requests to." J.L. Hussey, M.D., University of Wisconsin Hospitals. Department of Surgery, 1300 University Avenue. Madison. WI 53706, U.S.A.
276
R.S. Rankin and J.L. Hussey: Idiopathic Inferior Mesenteric Venous Thrombosis
Fig. I. Venous phase of inferior mesenteric arteriogram shows t h r o m b u s as a tubular filling defect (curved arrows), holding up contrast material in rectal vein. Short arrow points to minor notch defect probably from splenic vein flow dilution
Fig. 2. Venous phase of inferior mesenteric angiogram performed several days after initial study. Vasopressin has been infused and small veins are not visible, but widely patent main channel of interior mesenteric vein is demonstrated
[8] results in poor venous filling. Other inferential angiographic findings include prolongation of the arterial phase, increased contrast staining of the mucosa, and venous nonvisualization [3, 4, 8]. In our case, the relationship of the venous thrombosis to arterial bleeding is conjectural, but may relate to mucosal congestion and necrosis in a compromised bowel. Intra-arterial vasopressor promptly controlled the bleeding and it may be the treatment of choice in the poor-risk patients with this condition.
superior and inferior mesenteric veins: a report of a case. Am Surg 36.'235 237, 1970 Matthews, AE, White R R : Primary mesenteric venous occlusive disease. Am J Surg 122.'579 583, 1971 Naitove A, W e i s m a n RE: Primary mesenteric venous thrombosis. Ann Surg 161.'516, 1965 Nelson SW, Eggleston W: Findings on plain roentgenograms of the a b d o m e n associated with mesenteric vascular occlusion with a possible new sign of mesenteric vein thrombosis. Am J Roentgenol 83:886 894, 1960 N o o n a n C, R a m b o ON, Margulis A R : Effect of timed occlusion at various levels of mesenteric arteries and veins: correlative study of arteriographic and histologic patterns of rat gut. Radiology 90.'99 106,1968 Polk H C Jr: Experimental mesenteric venous occlusion I I I diagnosis and treatment of induced mesenteric venous thrombosis. Ann Surg 163:432 444, 1966 Schwartz S, Boley S, Schultz L, Allen A: A survey of vascular diseases of the small intestine. Seminars Roentgenol 1:178 185, 1966
4. 5. 6.
7.
8.
References 1. Berry FB, Bougis J: Agnogenic mesenteric venous thrombosis. Ann Surg 132:450 474, 1950 2. Clement A R , C h a n g J: The radiological diagnosis of spontaneous mesenteric venous thrombosis. Am J Gastroenterol 63.'209 215, 1975 3. Goldstone J~ More WS, Hall AP: Chronic occlusion of the
9.
ReceiL'ed." April 15, 1976," accepted." Ju[y 9, 1976
Gastrointest Radiol 1,275-276 (1976)
Radiology ,~ by Springer-Verlag 1976
Idiopathic Inferior Mesenteric Venous Thrombosis Demonstrated by Angiography R o n a l d S. R a n k i n a n d J o h n L. H u s s e y Department of Radiology and Surgery, Center for Health Sciences, University of Wisconsin, Madison, Wisconsin, U.S.A.
Abstract.
I d i o p a t h i c t h r o m b o s i s o f the i n f e r i o r m e s e n t e r i c vein, n o t a s s o c i a t e d w i t h p o r t a l v e i n t h r o m b o s i s , is an u n c o m m o n l y d i a g n o s e d lesion. W e are r e p o r t i n g a c a s e o f i n f e r i o r m e s e n t e r i c v e i n t h r o m b o s i s d i a g n o s e d p r e o p e r a t i v e l y by a n g i o g r a p h y . W e believe this to be the first c a s e in the l i t e r a t u r e o f this p a r t i c u l a r lesion d e m o n s t r a t e d c o n c l u s i v e l y by a n g i o g r a p h y b e f o r e surgery.
Mesenteric venous thrombosis, which does not develo p s e c o n d a r y to a n y c l e a r - c u t a n t e c e d e n t e v e n t ( b o w e l i n f a r c t i o n , v o l v u l u s , t r a u m a , etc.) a n d d o e s n o t p r i m a r ily i n v o l v e the p o r t a l c i r c u l a t i o n , is a d i s t i n c t clinical entity w h i c h has b e e n v a r i o u s l y d e s i g n a t e d as a g n o genic, p r i m a r y , o r s p o n t a n e o u s m e s e n t e r i c v e n o u s t h r o m b o s i s [1, 2, 5]. W e a r e r e p o r t i n g a case o f inferior m e s e n t e r i c v e i n ( I M V ) t h r o m b o s i s w h i c h w a s c o n clusively d e m o n s t r a t e d a n g i o g r a p h i c a l l y o n p r e o p e r a tive a n d f o l l o w - u p studies.
of blood, urine, and sputum were all negative. Her signs and symptoms waxed and waned for several weeks before she evidenced rectal bleeding, which was minor at first and was originally attributed to her hemorrhoids. Proctosigmoidoscopy to 25 cm revealed small amounts of "currant jelly" stool. She developed fresh rectal bleeding but refused a barium enema. Again she underwent proctosigmoidoscopy with negative findings. Therefore, a transfemoral arteriography was performed which showed a distal IMV thrombosis and an area of mucosal congestion in the rectum but no definite bleeding site (Fig. 1). She was treated with one unit of low molecular weight dextran intravenously. Anticoagulants were avoided because of the prolonged bleeding time, elevated prothrombin time, and thrombocytopenia. Uncontrolled bleeding from the arterial puncture site led to exploration of the femoral area and closure of the arterial puncture. Because of increased peritoneal irritation, she. at the same time, underwent exploratory laparotomy. This confirmed the IMV thrombosis but showed no evidence of bowel ischemia. Following surgery, the patient became unmanageably hypertensive and continued to have minor rectal bleeding requiring intermittent transfusion. Proctoscopy was done at the time for increased "currant jelly" bleeding. This did not show a bleeding point to the 20 cm level; and the bowel looked viable, although somewhat dusky at the 8 12 cm level. The same evening, she bled massively from the rectum. Repeat arteriography showed two large arterial bleeding sites about 10 cm from the anus. Bleeding quickly ceased with an intra-arterial vasopressin infusion. The IMV thrombus previously seen had completely resolved (Fig. 2). Several hours after the procedure, she became febrile, leukopenic, and confused. A gram-negative septic shock led to patient's death 4 days later.
Case Report
Discussion
This 47-year-old white female suffered from malignant hypertension and chronic renal failure for over 10 years. She had undergone splenectomy, bilateral nephrectomy, and a renal transplantation several months prior to admission to the hospital. There was no history of gastrointestinal bleeding except from hemorrhoids. The patient's complicated medical history also included episodes of cardiac decompensation, myocardial infarction, and even a successfully treated cardiac arrest. Her admission was prompted by cardiac failure and severe hypertension. Her white blood count was 23,000 mm 3. Cultures
I d i o p a t h i c i n f e r i o r m e s e n t e r i c v e n o u s t h r o m b o s i s is p r o b a b l y a r e l a t i v e l y r a r e c o n d i t i o n a n d it is q u i t e u n u s u a l to m a k e the d i a g n o s i s w h e n the t h r o m b u s i n v o l v e s o n l y a s m a l l v e i n s u c h as the I M V [1, 9]. T h e c l i n i c a l p i c t u r e is o f t e n v a g u e [4, 5], a n d the x - r a y f i n d i n g s a r e u s u a l l y n o t specific, a l t h o u g h s o m e f i n d i n g s o n p l a i n films a n d b a r i u m s t u d i e s h a v e b e e n d e s c r i b e d [2, 4, 6]. A n g i o g r a p h y has b e e n s u g g e s t e d in the diagn o s i s o f m e s e n t e r i c v e n o u s t h r o m b o s i s o n t h e basis o f e x p e r i m e n t a l w o r k [7, 8]. H o w e v e r , a c t u a l d e m o n s t r a t i o n o f t h e l e s i o n by a n g i o g r a p h y m a y be difficult as a r t e r i a l s p a s m t h a t o f t e n f o l l o w s v e n o u s o c c l u s i o n
Key words: I n f e r i o r m e s e n t e r i c vein, t h r o m b o s i s Angiography.
Address reprhTt requests to." J.L. Hussey, M.D., University of Wisconsin Hospitals. Department of Surgery, 1300 University Avenue. Madison. WI 53706, U.S.A.
276
R.S. Rankin and J.L. Hussey: Idiopathic Inferior Mesenteric Venous Thrombosis
Fig. I. Venous phase of inferior mesenteric arteriogram shows t h r o m b u s as a tubular filling defect (curved arrows), holding up contrast material in rectal vein. Short arrow points to minor notch defect probably from splenic vein flow dilution
Fig. 2. Venous phase of inferior mesenteric angiogram performed several days after initial study. Vasopressin has been infused and small veins are not visible, but widely patent main channel of interior mesenteric vein is demonstrated
[8] results in poor venous filling. Other inferential angiographic findings include prolongation of the arterial phase, increased contrast staining of the mucosa, and venous nonvisualization [3, 4, 8]. In our case, the relationship of the venous thrombosis to arterial bleeding is conjectural, but may relate to mucosal congestion and necrosis in a compromised bowel. Intra-arterial vasopressor promptly controlled the bleeding and it may be the treatment of choice in the poor-risk patients with this condition.
superior and inferior mesenteric veins: a report of a case. Am Surg 36.'235 237, 1970 Matthews, AE, White R R : Primary mesenteric venous occlusive disease. Am J Surg 122.'579 583, 1971 Naitove A, W e i s m a n RE: Primary mesenteric venous thrombosis. Ann Surg 161.'516, 1965 Nelson SW, Eggleston W: Findings on plain roentgenograms of the a b d o m e n associated with mesenteric vascular occlusion with a possible new sign of mesenteric vein thrombosis. Am J Roentgenol 83:886 894, 1960 N o o n a n C, R a m b o ON, Margulis A R : Effect of timed occlusion at various levels of mesenteric arteries and veins: correlative study of arteriographic and histologic patterns of rat gut. Radiology 90.'99 106,1968 Polk H C Jr: Experimental mesenteric venous occlusion I I I diagnosis and treatment of induced mesenteric venous thrombosis. Ann Surg 163:432 444, 1966 Schwartz S, Boley S, Schultz L, Allen A: A survey of vascular diseases of the small intestine. Seminars Roentgenol 1:178 185, 1966
4. 5. 6.
7.
8.
References 1. Berry FB, Bougis J: Agnogenic mesenteric venous thrombosis. Ann Surg 132:450 474, 1950 2. Clement A R , C h a n g J: The radiological diagnosis of spontaneous mesenteric venous thrombosis. Am J Gastroenterol 63.'209 215, 1975 3. Goldstone J~ More WS, Hall AP: Chronic occlusion of the
9.
ReceiL'ed." April 15, 1976," accepted." Ju[y 9, 1976
