Superior mesenteric vein thrombosis following laparoscopic Nissen fundoplication.

This report describes the second case of a superior mesenteric and portal vein thrombosis following an uneventful laparoscopic Nissen fundoplication. The patient presented on postoperative day 10 with acute onset of abdominal pain and inability to tolerate oral food. A computed tomography (CT) scan revealed superior mesenteric and portal venous thrombosis with questionable viability of the proximal small bowel. He was heparinized and taken for emergent exploratory laparotomy. At surgery and at a planned re-exploration the following day, the bowel was viable and no resection was needed. Despite continuation on anticoagulation therapy, he developed a pulmonary embolism. A hypercoagulable workup was normal. After continued anticoagulation therapy and supportive care, a duplex ultrasound 2 months after the event showed normal flow in both the superior mesenteric and portal veins. Possible mechanisms are discussed along with a review of the pertinent literature.     

Role of diagnostic laparoscopy in managing acute mesenteric venous thrombosis

We describe two cases with acute mesenteric venous thrombosis in which diagnostic laparoscopy helped to diagnose the possible bowel infarction. These patients presented with abdominal pain out of proportion to physical findings, and computed tomography demonstrated thrombus in the superior mesenteric vein. Anticoagulation with heparin followed by diagnostic laparoscopy was done immediately after the diagnosis was established. According to the laparoscopic findings, one was managed with full anticoagulation without laparotomy and the other was managed with full anticoagulation and surgical resection. Considering that delay in diagnosis and surgical exploration is still frequent and is a significant contributory factor to the reported high mortality rate, diagnostic laparoscopy in an early position in the management algorithm for acute mesenteric venous thrombosis can furnish a rapid precise diagnosis of bowel infarction. It can also reduce the unnecessary laparotomies in these difficult cases.     

Clotting problems: diagnosis and management of underlying coagulopathies

Vessel wall injury, stasis, and blood hypercoagulable state are major predisposing factors of thrombosis. Although, a procoagulable factor is found in half of patients with venous thromboembolism, relatively little is known about coagulopathies that predispose to arterial thromboembolism or unexplained arterial revascularization thrombosis. Those hypercoagulable states can be inherited or acquired and related to either an increase of a procoagulable factor or a decrease of an anticoagulation agent. However, most thrombotic episodes seem to occur with additive combination of acquired and inherited predisposing factors. Therefore, controversy exists as to which patients and family members to test for thrombophilia and which patients to treat with life-long anticoagulation. The aim of this review is to provide a practical overview with guidelines for detecting, and treatment of, the principal underlying coagulopathies that a vascular surgeon should be aware of in his/her practice and for the care of patients with vascular disease.     

肠系膜静脉血栓形成的诊断和手术时机探讨

目的 探讨肠系膜静脉血栓形成(MVT)的诊治及手术时机。方法 回顾性分析9例MVT的临床资料,总结其既往史、发病时间与治疗方式、手术与非手术病人的临床表现和抗凝溶栓治疗的效果。结果 MVT发病以腹痛为主,9例之中有7例病人既往有血液高凝状态的病史。早期确诊的4例病人应用抗凝溶栓治疗,有3例非手术治愈。其余5例在发病后20～144h因腹膜炎而手术探查时确诊。手术切除肠管30～320cm。由于术后没及时应用抗凝治疗,1例发生了肠坏死而再次手术。结论 早期诊断、早期抗凝溶栓治疗能避免肠坏死,一旦出现腹膜炎或肠绞窄体征是手术探查的指征。手术时要正确判断尚有生机的肠管和尽量取出门静脉和肠系膜上静脉主干内的血栓。手术后继续抗凝溶栓治疗是保证疗效的关键。     

Protein C deficiency. A cause of unusual or unexplained thrombosis

Familial hypercoagulable states are a collection of syndromes characterized by an inherited deficiency of various proteins involved in the control of coagulation and include antithrombin III, plasminogen, protein C, and protein S. Affected patients usually develop venous thrombosis as adults. During a 15-month interval, we identified five patients with venous thrombosis accompanied by protein C deficiency. Four patients presented with deep venous thrombosis, which was recurrent in two, and one patient developed mesenteric venous thrombosis. The kindred of this last patient suggested an autosomal dominant genetic transmission of protein C deficiency. Patients' ages at the time of diagnosis of disease ranged from 28 to 41 years. All patients had low levels of protein C (range, 34 to 67 U/dL; normal, 70 to 130 U/dL). All patients were treated with heparin sodium immediately and then given long-term oral anticoagulation therapy with warfarin sodium. Protein C deficiency is a predisposing factor to the development of venous thrombosis that has only recently been recognized. Treatment of symptomatic protein C deficiency requires short-term heparin therapy followed by long-term oral anticoagulation therapy with warfarin. Oral anticoagulation treatment must be initiated slowly with no loading dose to avoid warfarin-associated skin necrosis. Patients with unexplained or unusual thrombosis, especially if it occurs at an early age, and patients with recurrent episodes of lower limb venous thrombosis should have their protein C levels measured. If a deficiency is documented, long-term warfarin anticoagulation therapy is recommended.     

Antiphospholipid syndrome with anti-prothrombin autoantibodies in a patient with an axial-flow left ventricular assist device.

Autoantibodies to prothrombin, first described almost 50 years ago, are paradoxically associated with thrombosis. Described is an unusual case of fatal hypercoagulability in a patient with multiple arterial and venous thromboembolic complications despite intense anticoagulation while being bridged to transplantation with a left ventricular assist device. Serum analysis revealed the presence of prothrombin autoantibodies and high titers of anti-nuclear antibodies, and autopsy revealed pulmonary arteriolar vasculitis. These findings suggest an autoimmune basis for the presence of anti-prothrombin antibodies and the hypercoagulable state observed in the present case.     

Portal vein thrombus after pediatric proctocolectomy with ileoanal anastomosis

In adults, mesenteric venous thrombosis with extension into the portal system is a known complication of total proctocolectomy with pouch ileoanal anastomosis. Although frequently reported in adults, this complication is rare in pediatric patients undergoing this operation. We report 2 cases of adolescent patients with ulcerative colitis who experienced portal vein thrombosis after this procedure. Both were treated with systemic anticoagulation therapy with complete resolution of their clots. We recommend that mesenteric/portal venous thrombosis be considered in the differential diagnosis in any child presenting with fever, abdominal pain, and leukocytosis after restorative proctocolectomy with ileal pouch anastomosis and that imaging obtained to evaluate abdominal complaints in this population be directed toward ruling out this complication.     

Mesenteric vein thrombosis due to factor V Leiden gene mutation.

BACKGROUND: Mesenteric venous thrombosis is a rare cause of acute abdominal pain that may be the result of coagulation abnormalities. METHODS: Four consecutive patients with mesenteric venous thrombosis underwent haematological evaluation. RESULTS: All four had activated protein C resistance resulting from a single mutation in the gene coding for coagulation factor V. Three had surgery; in one patient the diagnosis was made by ultrasonography. One of the patients who had surgery died but the other three survived and were treated with long-term anticoagulation. CONCLUSION: Activated protein C resistance may be an important pathogenetic factor in primary mesen-teric vein thrombosis.     

Mesenteric venous thrombosis.

Mesenteric venous occlusion produces a spectrum of clinical presentations, the most common of which is the acute onset of abdominal pain with progressive signs and symptoms of bowel infarction. This acute form of mesenteric venous thrombosis, compared with other forms of acute mesenteric infarction, occurs in younger patients, typically has a more indolent and nonspecific course, involves shorter segments of bowel, and has a lower mortality rate. In contradistinction to our recommended therapy in other forms of acute mesenteric infarction, immediate anticoagulation is indicated for mesenteric venous thrombosis. Second-look operations are used, as in other forms of acute mesenteric infarction, whenever portions of bowel of questionable viability are not resected at the primary operation. Chronic mesenteric venous thrombosis may produce no symptoms or may cause gastrointestinal bleeding from portal hypertension. Newer imaging techniques have increased the ability to diagnose and define the extent of all forms of mesenteric venous thrombosis and have added to the therapeutic options available to manage them.     

Management of Thrombophilia in Renal Transplant Patients

Renal allograft recipients with thrombophilia (a hypercoagulable state) are at higher risk for early allograft loss. Following an episode of allograft renal vein thrombosis in a patient subsequently diagnosed with protein C deficiency, we adopted universal screening for hypercoagulable risk factors. Patients with a history of a thromboembolic event underwent laboratory screening for thrombophilia. Eight patients with a defined hypercoagulable disorder or a strong clinical history of thrombosis even in the absence of hematologic abnormalities were treated with anticoagulation following renal transplantation. We reviewed the outcomes of these eight patients and all renal transplant recipients at our center who developed thrombotic complications after renal transplantation. Since the introduction of universal screening for hypercoagulable risk factors, 235 consecutive transplants were performed without allograft thrombosis. Eight patients with evidence of thrombophilia, recognized before renal transplantation, received perioperative heparin and postoperative oral anticoagulation. Two of these eight patients developed perinephric hematomas requiring evacuation, blood transfusion, and temporary withholding of anticoagulation. Of interest, two of the remaining 227 patients, not identified with thrombophilia before surgery, developed thrombotic complications after renal transplantation. A hypercoagulable disorder was subsequently documented in each. Identifying patients with thrombophilia before transplantation and defining their management presents many challenges. The risk of allograft thrombosis must be weighed against the risk of perioperative bleeding and the need for long-term anticoagulation. Recommendations for managing thrombophilia in renal transplant recipients are suggested based on our experience and review of the literature.     

Mesenteric vascular occlusion resulting in intestinal necrosis in children

PURPOSE: The records of 4 patients who had necrotic bowel secondary to acute mesenteric vascular occlusion affecting various levels of mesenteric vasculature were reviewed to determine the clinical manifestations, diagnostic investigations, predisposing factors, complications, and outcome of mesenteric vascular thrombosis in children. METHODS: The medical records of the patients (3 boys, 1 girl) treated between 1981 and 1996, inclusive, for bowel infarction secondary to mesenteric vascular thrombosis, were reviewed with regard to signs and symptoms, laboratory tests, radiological investigations, surgical findings, histopathologic examinations, and outcome. RESULTS: The ages of the patients ranged between 1 and 14 years with a mean age of 8.2 years. Initial symptoms, present in all patients, were abdominal pain, abdominal distension, and tenderness. Laboratory and radiological findings including abdominal radiographs and abdominal ultrasonography were nondiagnostic. Selective superior mesenteric angiography showed complete obliteration of the superior mesenteric artery with absence of venous return in 1 case. Three patients with massive intestinal necrosis died of multiorgan failure or the complications of short bowel syndrome. Histological examination of the resected intestinal segments showed the typical findings of polyarteritis nodosa in 2 patients. One patient had a previous history of right femoral vein thrombosis, whereas 1 patient had no known underlying disorders predisposing vascular thrombosis. CONCLUSIONS: Mesenteric vascular occlusion is a rare but serious disease leading to death in children. The patients present with similar clinical signs, most frequent and important are acute abdominal pain, vomiting, and distension. Mesenteric vascular occlusion is a rare cause of acute abdomen in childhood, which requires urgent diagnosis and intervention. In suspected mesenteric vascular insufficiency, angiography should be performed followed by intraarterial thrombolytic infusion therapy in selected cases. When intestinal infarction is suspected, immediate surgical resection of compromised bowel is necessary with appropriate postoperative anticoagulation or treatment of any underlying disease.     

Successful treatment of acute symptomatic extensive portal venous system thrombosis by 7-day systemic thrombolysis

Acute portal venous system thrombosis (PVST) can cause acute mesenteric ischemia and even intestinal infarction, which are potentially fatal, and requires recanalization in a timely fashion. Herein, we report a 56-year-old man with acute non-cirrhotic symptomatic extensive PVST who achieved portal vein recanalization after systemic thrombolysis combined with anticoagulation. Initially, anticoagulation with enoxaparin sodium for 4 d was ineffective, and then systemic thrombolysis for 7 d was added. After that, his abdominal pain completely disappeared, and portal vein system vessels became gradually patent. Long-term anticoagulation therapy was maintained. In conclusion, 7-d systemic thrombolysis may be an effective and safe choice of treatment for acute symptomatic extensive PVST which does not respond to anticoagulation therapy.     

Upper-extremity deep venous thrombosis following humeral shaft fracture

Upper-extremity deep venous thrombosis (DVT), although not as common as its lower-extremity counterpart, is a clinical entity with potentially devastating complications. Approximately 1% to 4% of all DVT cases involve the upper extremity, with 9% to 14% of these cases complicated by pulmonary embolism. Prompt diagnosis with duplex ultrasonography and subsequent anticoagulation are the gold standards for identification and treatment. The majority of these cases are secondary to medical comorbidities such as malignancy, hypercoagulable states, and indwelling catheters. Although rare, several case reports of orthopedic-related upper-extremity DVT are present in the literature. This article reports a case of upper-extremity DVT in a humeral shaft fracture treated nonoperatively. A 58-year-old man presented with right elbow pain after a fall from scaffolding. Radiographs demonstrated a distal humeral shaft fracture at the tip of a previously placed intramedullary nail. Initial treatment consisted of closed reduction in a coaptation splint. The patient re-presented 4 days later with increasing forearm pain and swelling. An ultrasound revealed an extensive thrombus of the right brachial vein. A coaptation splint was replaced and the patient was admitted to the hospital for therapeutic anticoagulation. After hematology consultation and a short hospitalization, the patient was discharged home on a 3-month course of Warfarin. The goal of treatment of upper-extremity venous thrombosis is to improve the patient's acute symptoms and prevent both pulmonary embolism and post-thrombotic syndrome. Post-thrombotic syndrome is a chronic, potentially debilitating condition that occurs in approximately 15% of upper-extremity DVT cases with symptoms consisting of pain, swelling, paresthesias, and functional limitation.     

Mesenteric vein thrombosis following impregnation via in vitro fertilization-embryo transfer

Pregnancy is an acquired hypercoagulable state. Most patients with thrombosis that develops during pregnancy present with deep vein leg thrombosis and/or pulmonary embolism, whereas the development of mesenteric vein thrombosis(MVT) in pregnant patients is rare. We report a case of MVT in a 34-year-old woman who had achieved pregnancy via in vitro fertilization-embryo transfer(IVFET). At 7 wk of gestation, the patient was referred to us due to abdominal pain accompanied by vomiting and hematochezia, and she was diagnosed with superior MVT. Following resection of the gangrenous portion of the small intestine, anticoagulation therapy with unfractionated heparin and thrombolysis therapy via a catheter placed in the superior mesenteric artery were performed, and the patient underwent an artificial abortion. Oral estrogen had been administered for hormone replacement as part of the IVF-ET procedure, and additional precipitating factors related to thrombosis were not found. Pregnancy itself, in addition to the administered estrogen, may have caused MVT in this case. We believe that MVT should be included in the differential diagnosis of a pregnant patient who presents with an acute abdomen.     

Internal jugular vein thrombosis in association with the ovarian hyperstimulation syndrome

Thrombosis of the internal jugular vein is a rare entity with the potential for serious consequences. Most of the reported cases of jugular venous thrombosis have occurred in the presence of an indwelling venous catheter, an established hypercoagulable state, or in association with head and neck sepsis. This report presents a case of a patient in whom jugular venous thrombosis developed during the first trimester of pregnancy after in vitro fertilization. Thromboembolism in these circumstances can be related to a condition known as the ovarian hyperstimulation syndrome. The presentation of severe neck pain in pregnant women, especially in those who have undergone assisted reproduction procedures, should prompt evaluation by duplex scan to evaluate the jugular veins for thrombosis. Anticoagulation is the treatment of choice.     

急性原发性肠系膜上静脉血栓形成17例临床诊治分析

目的:探讨急性原发性肠系膜上静脉血栓形成(APSMVT)的临床诊断与治疗。方法:回顾性分析我院1998年至2007年收治的17例APSMVT的临床资料。结果:17例病人(100%)均有持续性渐行加重的腹痛,常见伴随症状有恶心呕吐(82%)、消化道出血(53%)、肠梗阻(53%)、发热(59%)等。11例(65%)腹腔穿刺获血性腹水。17例均行超声检查,1例术前明确诊断;14例CT检查中2例增强扫描后得以确诊,12例平扫可见间接征象。16例行坏死肠段切除手术及抗凝治疗,其中3例首次剖腹探查未见异常,在症状未缓解或加重后再次手术发现肠坏死并行肠切除。2例病人行经皮肝穿刺肠系膜上静脉导管溶栓治疗,1例血栓复发者行肠系膜上动脉导管溶栓后治愈。3例术后因脓毒症死亡。结论:APSMVT术前诊断困难,对不明原因急性剧烈腹痛者应及时怀疑本症,早期发现、早期治疗方能提高本病的治愈效果。病程早期可采用介入溶栓疗法,后期出现肠坏死征象者应及时手术,并予以抗凝治疗。     

An outpatient anticoagulation protocol managed by a vascular nurse-clinician

Lifetime anticoagulation has become a therapeutic option for surgical patients with hypercoagulable states or prosthetic arterial bypass grafts. However, physicians may not achieve optimal anticoagulation or may attempt to limit the length of the therapy period because of the perceived morbidity from hemorrhagic complications of Coumadin therapy. A protocol for anticoagulant therapy monitored and regulated by a vascular nurse-clinician was reviewed. Coumadin was prescribed for 1,891 patient-months to 93 patients to maintain their prothrombin time 1.5 to 2 times control (range: 18 to 24 seconds). The mean (+/- SD) prothrombin time for the study population was 19.8 +/- 1.8 seconds. During follow-up, 472 (14%) of 3,479 prothrombin times measured were below the therapeutic range (n = 232) or prolonged (n = 240), prompting an adjustment in the Coumadin dose in 82 (88%) patients. Four patients developed recurrent vascular graft thrombosis while receiving anticoagulation. There were 6 major and 11 minor hemorrhagic complications. Patients with a chronic risk for arterial or venous thrombosis can have out-patient anticoagulant therapy administered at optimal intensity and regulated safely with a low incidence of hemorrhagic and thrombotic events.     

Mesenteric venous thrombosis

Sixteen patients with mesenteric venous thrombosis were reviewed retrospectively during a period from 1983 to 1987. Twelve patients had progressive abdominal pain, three had gastrointestinal bleeding, and one had general malaise. Seven of these 16 patients had previous deep-vein thrombosis. After negative routine gastrointestinal and hepatobiliary evaluation, 11 patients underwent an infusion computerized tomographic scan. Of these, 10 had superior mesenteric vein thrombosis; three of these 10 patients had portal vein thrombosis. Selective arteriography was done in two patients because of gastrointestinal bleeding, and a diagnosis of mesenteric vein thrombosis was made on the venous phase of the examination. The remaining four patients developed acute abdominal symptoms requiring surgical exploration, at which time mesenteric venous thrombosis was discovered. An identifiable coagulopathy was detected in nine patients (protein C deficiency in six, protein S deficiency in two, and factor IX deficiency treated with factor IX concentrate in one). No case of congenital antithrombin-III deficiency was identified. Six of these nine patients had a past history of deep venous thrombosis. Of five patients who underwent surgical exploration, all required bowel resection. In follow-up, two patients died of intestinal necrosis and a third died of associated pancreatic cancer. Thirteen patients were discharged from the hospital. Treatment of coagulopathy was by heparin in three patients and sodium warfarin (Coumadin) in four patients. Long-term anticoagulation was not instituted because of gastrointestinal bleeding in three and cirrhosis in three patients. Mesenteric venous thrombosis can occur without gangrenous bowel. Diagnosis should be suspected when acute abdominal symptoms develop in patients with prior thrombotic episodes and a coagulopathy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Venous claudication in a child with thrombophilia

Deep venous thrombosis (DVT) rarely occurs in active children. Its presence usually suggests an inherited or acquired hypercoagulable state. Occasionally mechanical obstruction may be the inciting factor in this process. Initial management usually consists of sequential heparin and warfarin anticoagulation. We present the management of DVT in an adolescent girl with elevated levels of C-reactive protein and lupus anticoagulant. Venous claudication and severe lower-extremity swelling on ambulation complicated her course. After more than 2 weeks of conservative therapy with anticoagulation thrombolytic therapy was instituted. This was terminated early because of mild hematuria. However, follow-up duplex scan at 2 years has shown complete resolution of the iliofemoral thrombosis. Spontaneous DVT in children differ from that in adults in that an underlying etiology can usually be uncovered. These differences are explored.     

Prospective screening for deep vein thrombosis in high risk patients

Doppler ultrasound screening of deep vein thrombosis has been carried out in four high risk groups of surgical patients, including those undergoing total hip replacement, gastric bypass for morbid obesity, major abdominal surgery, and major amputation of the lower extremity. None of these groups of patients received prophylactic anticoagulation. There was a 4 per cent incidence of deep vein thrombosis in 101 patients undergoing total hip replacement. Only one of the fifty-eight patients undergoing gastric bypass suffered a postoperative venous thrombosis. None of the sixty-three patients undergoing major abdominal surgery or the thirtyfive patients undergoing amputation developed venous thrombosis. Doppler ultrasound is a simple, rapid, accurate noninvasive technic for prospective screening of high risk patients for deep vein thrombosis. Such a program may be a useful alternative to routine prophylaxis of patients at risk of venous thromboembolic disease.