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Clinical Section

Periodic (Edema in a Man Gerald H Tomkin MD MRCP (Dudley Road Hospital, Birmingham, B18 7QH)

ments, to Professor V H T James (St Mary's Hospital) for the aldosterone measurements, and to Dr J Jackson (Birmingham University) for the capillary permeability studies.

T M, man aged 48 History: Admitted in 1956 with an episode of swelling of legs and backache following a 'cold'. Since then, the patient has been periodically admitted with recurrent attacks of leg cedema, which respond promptly to bed rest. He has been unable to work since 1969, as he found it too uncomfortable to continue standing after 4.00 pm and required two days of bed rest a week to control the swelling. On examination: (September 1973) The patient was obese, with ankle and leg aedema. Blood pressure (readings taken on a tilt table): 125/80 (recumbent), 120/100 (standing). Investigations: ECG and Chest X-ray - normal. Total proteins - 8.3 g/100 ml. Serum albumin 4.85 g/100 ml. Blood urea - 43 mg/100 ml. Na 142, K - 4.3 mmol/l; 24-hour urinary protein 280 mg. Lymphangiogram and venogram (1969) normal. Creatine clearance - 123 mI/min (recumbent), 21.1 ml/min (standing). Water load test (1500 ml) - recumbent: 1500 ml excreted within 4 hours. Standing: 250 ml excreted within 4 hours. After a and P blockade, standing: 1050 ml excreted. Urinary metanephrines - 347 ,g/24 hours. Plasma renin: 2.84 ,tg/h/ml (recumbent), 4.73 ,g/h/ml (standing 4 hours later, on 100 mEq Na diet); both results within the normal range. Aldosterone: 3 ng/100 ml (recumbent), 11.0 ng/100 ml (standing 4 hours later, on 100 mEq Na diet); both results within the normal range. Capillary filtration ccefficient - 0.02 ml per min per mmHg per 100 ml tissue (normal). IVP and renal angiogram showed the left kidney to drop considerably when the patient was tilted to the upright position.

REFERENCES Gill J R, Cox J, Delea C & Bartter F C (1972) AmerIcan Journal ofMedicine 52,444 451 Gill J R, Waldman T A & Bartter F C (1972) American Journal ofMedicine 52, 452-456 Hill S R, Hodd W G, Farmer T A & Burnum J F (1960) New EnglandJournal ofMedicine 263, 1342-1345

Comment The syndrome of periodic cedema is well known in women. The mechanism is not understood, though abnormalities in albumin metabolism (Gill, Waldmann & Bartter 1972), aldosterone (Hill et al. 1960) and an increase in adrenergic activity (Gill, Cox, Delea & Bartter 1972) have been recorded. The syndrome in males has not, to my knowledge, been documented. The results of treatment by a and 8 blockade suggest that adrenergic activity, perhaps through the renin angiotensin system, is involved. It is postulated that the postural mechanism may be related to the position change of the left kidney. Acknowledgments: I am grateful to Dr J D H Slater (Middlesex Hospital) for the renin measure-

Professor J R Hobbs said that as one who had participated in the original studies of the effect of posture on renal clearances, he could assure them that none of their subjects ever showed such a dramatic reduction in creatinine clearance. Since the rest of this patient's syndrome and findings could all be explained by that reduction, he would encourage them to see if a good surgeon could improve the blood flow through the patient's kidney(s) when in a vertical position. With forethought, this might even be checked during the operation. Mr A P Wyatt said that a radioactive renogram might give further information about the suspected dramatic change in renal blood flow with variation in posture if it could be performed with the patient lying down and then standing. He was doubtful that a nephropexy would cure the complaint because although there was undoubted change in position of the kidney with posture there was no obvious kinking or other obstruction to the renal artery. It was not certain that the movement of the kidney that had been demonstrated with posture was outside the expected normal range.

Idiopathic Mesenteric Vein Thrombosis A M Whiteley MB MRCP1 (for L M Blendis MD MRCP) (Central Middlesex Hospital, London NWIO 7NS) M P, woman aged 55 History: Intermittent abdominal pain for three years. Mild diabetes. June 1973 admitted with one week severe constant abdominal pain, anorexia, occasional vomiting and loose stools. On examination: Looked well with obese abdomen and minimal tenderness. Varicose veins and superficial thrombophlebitis noted. Only abnormal investigations were ESR 92 mm in 1 hour (Westergren) and blood sugar 255 mg/ 100 ml. Over 72 hours she deteriorated with increased pain, tachycardia, vomiting and low fever. Abdomen became distended with tenderness and 'Present address: The London Hospital,

Whitechapel, London ElI BB

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rebound. Abdominal X-ray showed 2 distended loops. Laparotomy revealed that 80 cm of jejunum and ileum were plum coloured and necrotic, merging with viable bowel. There was a thick cedematous mesentery, large lymph nodes, pulsatile arteries and thrombosed veins. Other organs were normal. Resection of necrotic bowel, leaving 2 feet of jejunum and ileum which were anastomosed. Histology showed hemorrhagic infarction of small bowel with patent normal arteries and extensive venous thrombosis with early organization. Treated with i.v.fluids, nasogastric suction, ampicillin, hydrocortisone and insulin (initially not anticoagulated). Made an unremarkable recovery. Long-term management with 1000 calorie diet to control diabetes and maintain weight at 160 lb and warfarin from four weeks postoperative to present time.

The signs usually gradually change to peritonitis. Laparotomy shows patent arteries and variable thrombosis of mesenteric veins. The bowel varies from cedematous but viable to extensively necrotic. Resection with anastomosis is usually performed. In early cases thrombectomy is successful (Inahora 1971). Rethrombosis, both early and late, breakdown of anastomosis and intestinal obstruction are complications. Immediate anticoagulation with heparin and indefinite long-term oral anticoagulation are recommended. Surgery with anticoagulants has mortality of 15% but without anticoagulants about 50%. Mesenteric thrombosis with the contraceptive pill is similar but usually more rapid. There is mortality of 50 % with or without anticoagulants (Rose 1972).

Discussion Most cases of mesenteric vein thrombosis are secondary (Berry & Bougas 1950) to some local bowel disease, injury, after surgery, obstruction to portal system or hypercoagulation states, such as the contraceptive pill (Rose 1972). Idiopathic types, where no cause can be found, contribute about 5 %. Idiopathic thrombosis occurs more commonly in elderly males (Matthews & White 1971) with associated vascular disease (myocardial infarction, pulmonary embolus, thrombophlebitis) and mild diabetes. The main symptom is abdominal pain of no definite features usually of days or weeks duration. Associated features are nausea, vomiting, anorexia and change in bowel habit. Examination usually shows a mildly distended and tender abdomen with bowel sounds and little systemic upset. Investigations are unrewarding. Plain X-ray can show constant dilated loops of bowel. Mesenteric arterial angiogram is characteristic.

Summary Idiopathic mesenteric vein thrombosis is an uncommon condition of unknown etiology. It is difficult to diagnose but with prompt treatment the prognosis is good. REFERENCES Berr F & Bougas J (1950) Annals of Surgery 132,459 iahora T (1971) Annals ofSurgery 174,956 Matthews J & White R (1971) American Journal ofSurgery 122, 579 Rose M (1972) Postgraduate MedicalJournal 48, 430

Mr S L Strange said that he had treated a man of 54 with idiopathic mesenteric venous thrombosis but, unlike Dr Whiteley's case, he arrived in hospital in a very collapsed condition and had to have all but three feet of his small intestine resected. It was of interest that the year before sustaining mesenteric venous thrombosis he had pulmonary embolism from deep vein thrombosis in the left leg and this was treated for a period with anticoagulant therapy.