Mensenteric venous thrombosis

1. Mesenteric Vascular Disease:
Venous Thrombosis
T.Ruangpratyakul, MD

2. Epidemiology
• middle-aged, older adult
• 2.7:100,000
• Primary: spontaneous, idiopathic thrombosis
• Secondary: any condition known to predispose to MVT

3. Risk Factor
• increased risk for MVT post
laparoscopic surgery
• obesity with Roux-en Y
• extensive mobilization
mesenteric, portal splenic vein

4. Natural History
• uncommon disease
• not detected by routine lab
• transmural intestinal infarction
• 30% mortality rate after EL
• PVT 10x > MVT
• symptom 92% MVT , 33-45% bowel gangrene
• 1/4 IBD have thrombosis

5. Pathology
• 94% of MVT had intestinal infarction 0% in PVT
• bowel ischemia: extent of thrombosis, venous circulation,
occlusion, collateral flow
• limited segment of intestinal ischemia, edema, swelling,
reddish discoloration
• bowel infarction limited to jejunum or ileum

6. • acute/chronic: 4 wk cut off
Diagnosis
Hx+PE
• diffuse abd pain
• N/V
• Diarrhea
• LGIB
• FH of DVT
• CRP ^
• localized peritonitis
Laboratory
• D-dimer (normal R/O)
• inherited disorder
• acquired disorder
Noninvasive and Invasive
• MDCT
• laparoscopy
- MVT c discont VKA
- anticoag c abd pain
peritonitis

7. CT finding
1. thrombosis
2. dilated and
edematous bowel
loops
3. ascites

10. Treatment and Results
• 1st-line: conservative with anticoagulation, NPO, NG,
Fluid+electrolyte, analgesics, TPN
• ATB for risk of sepsis patients
• laparotomy and bowel resection
• rt-PA; total dose 100 mg for 48 hr
• Endovascular with heparin infusion +- bowel resection
1. At admit: late presentation/Dx
2. wks: failure of anticoag
3. months: late bowel stricture
4. At admit: late presentation/Dx
5. wks: failure of anticoag
6. months: late bowel stricture

11. Medical Treatment
• Heparin continous infusion ,keep aPTT 50-70 sec q 4 hr
• serial PE, daily lab: WBC, CRP
• when GI normal: start LMWH or VKA or DOAC
• Lifelong VKA or LMWH for VKA contraindicated patient
• 20% in hospital mortality, overall 30 day survival 80%
• 5-year survival 70%

12. Medical Treatment
• Heparin continous infusion ,keep aPTT 50-70 sec q 4 hr
• serial PE, daily lab: WBC, CRP
• when GI normal: start LMWH or VKA or DOAC
• Lifelong VKA or LMWH for VKA contraindicated patient
• 20% in hospital mortality, overall 30 day survival 80%
• 5-year survival 70%

13. Endovascular Treatment
• TIPS with mechanical aspiration thrombectomy and direct thrombolysis
• consider thrombolysis contraindication
• balloon angioplasty
• local thrombolysis: significant bleeding complication 60%
• heparin after endovascular
• VKA or DOAC when GI normal
• Doppler U/S at 1, 3, 6 month
cerebral infarction
<6wk
Hx of ICH
malignant tumor
brain AVM
severe DR
GIB
EV

14. Surgical Treatment
• indication: peritonitis, severe GIB, SMB perforation, intestinal
stricture
• surgical thrombectomy with bowel resection with heparinization with
second look laparotomy
• primary bowel anastomosis
• 2nd look: reduce unnecessary bowel resection
• post-op: heparin, bowel rest, TPN
• LMWH or VKA lifelong

15. Surgical Treatment
• CT: post-op, 6 month after anticoagulant
• survival rate after bowel resection: 80%
• complication: pneumonia, wound infection, renal failure,
sepsis, GI bleeding
• short-bowel syndrome is rare

18. THANK YOU