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Small Intestinal Stricture Complicating Superior Mesenteric Vein Thrombosis. a Study of Three Cases Gut: First Published As 10.1136/Gut.37.2.292 on 1 August 1995

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Small Intestinal Stricture Complicating Superior Mesenteric Vein Thrombosis. a Study of Three Cases Gut: First Published As 10.1136/Gut.37.2.292 on 1 August 1995 292 Gut 1995; 37: 292-295 Small intestinal stricture complicating superior mesenteric vein thrombosis. A study of three cases Gut: first published as 10.1136/gut.37.2.292 on 1 August 1995. Downloaded from C Eugene, D Valla, L Wesenfelder, A Fingerhut, A Bergue, J Merrer, C Felsenheld, A Moundji, J-C Etienne Abstract Previous history included cocaine addiction, Mesenteric vein thrombosis associated which ended in 1984. There was no history of with intestinal stricture, as a consequence thrombosis in the family. Investigations per- of intestinal ischaemia, has only been formed in another hospital showed leucocytosis mentioned twice in published works. The whereas the pancreatic enzymes and hepatic clinical, biological, and morphological function tests were normal. Ultrasonography aspects as well as the treatment of this and computed tomography were not contribu- morbid association were studied in three tive. Upper gastrointestinal endoscopy showed patients. In all, a two stage clinical course a congestive gastropathy. Upon admission on (initial acute abdominal pain and fever, 25 November 1990, physical examination was followed by chronic intestinal obstruc- normal. Leucocytosis was still present. The tion), corresponding to the sequence head of the pancreas was found to be heteroge- thrombosis/stricture, was found. x Ray neous on endosonography, computed tomo- studies showed a regularly contoured graphy, and nuclear magnetic resonance. The intestinal stricture. Surgical resection was main pancreatic duct was found to be normal required in all three cases for stricture, on endoscopic retrograde choliopancreatic- associated in one case with mesenteric ography. The biliary duct was not opacified. infarction. Anticoagulation treatment was There was no erosive duodenitis. Ultra- used to preclude recurrence. Increased sonography and duplex scanning showed clinical awareness could lead to the diag- thrombosis of the portal vein with cavemoma nosis of intestinal stricture secondary to and splenomegaly. Computed tomography and mesenteric vein thrombosis more often nuclear magnetic resonance showed that both and at an earlier stage. Treatment the portal and superior mesenteric veins were consists of evaluation of predisposing thrombosed, as confirmed by arteriograms, features, intestinal resection when neces- which showed hepatopetal flow in the caver- http://gut.bmj.com/ sary, and anticoagulation therapy, as noma and gastric varices. Colonoscopy showed indicated. an adenoma. Haematological tests were nega- (Gut 1995; 37: 292-295) tive except for the presence of antiphospholipid antibody, but this abnormality was not found Keywords: mesenteric vascular occlusion, mesenteric ultimately (see Table II). Heparin therapy was veins, thrombosis, jejunum, small bowel obstruction, intestine. started 1 December 1990. On 21 December, Hepatology and the patient presented with proximal intestinal on September 28, 2021 by guest. Protected copyright. Gastroenterology Unit obstruction. A barium follow through and C Eugene L Wesenfelder computed tomography were thought to be con- Mesenteric ischaemia resulting from portal or sistent with jejunal haematoma. Total paren- General and Digestive superior mesenteric venous thrombosis can be teral nutrition was started. As these symptoms Surgery Unit A Fingerhut seen in patients without hepatic disease or persisted and a second barium follow through A Moundji ongoing abdominal disease.' 2 Apparently showed a stricture (Fig 1), an exploratory J-C Etienne primitive venous thrombosis is most often laparotomy was performed on 25 January Pathology Department associated with patient or latent myeloprolifer- 1991. A jejunal stricture was found at 30 cm A Bergue ative syndromes or coagulation disorders.' 3-5 from the duodenojejunal flexure, associated C Felsenheld Mesenteric vein thrombosis can lead to sub- with adherence to the omentum, which was Medical Intensive Care acute reversible manifestations (such as severe, resected as well. Histopathological study (by Unit often mid-abdominal pain, occasionally resem- J Merrer bling abdominal angina, associated with or 3 6-8 or Centre Hospitalier without intestinal haemorrhage)2 Intercommunal, mesenteric infarction.9 The development of Poissy, France intestinal stricture has only been mentioned in two 6 We described the characteristics Hepatology and cases.2 Gastroenterology Unit, of intestinal stricture secondary to mesenteric Piti6 Salp6triere venous thrombosis based on our experience in Hospital, Paris, three cases. France D Valla Correspondence to: Professor C Eugene, Centre Case reports Hospitalier Intercommunal, 10 rue du Champ Gaillard, 78303 Poissy Cedex, France. Case report 1 Accepted for publication A 36 year old man was referred to our hospital Figure 1: Small intestinefollow through showing a long, 19 December 1994 in November 1990 for acute abdominal pain. regularly contoured stricture (case 1). Small intestinal stricture complicating superior mesenteric vein thrombosis. A study ofthree cases 293 intestines were not volvulated. Histopatho- .............. logical examination showed haemorrhagical infarction with numerous recent thrombosis of the veins in the submucosa and of larger mesenteric veins. The patient was given Gut: first published as 10.1136/gut.37.2.292 on 1 August 1995. Downloaded from heparin postoperatively and made an unevent- ful recovery. Research for haematological disease was negative (Table II). Coumarin therapy was started. No relapse was seen at the last follow up visit in September 1994. Case report 3 A 54 year old man was admitted to hospital in proximal dilatation (case 3). November 1991 for acute abdominal pain. There was a history of appendicectomy, hyper- I Bad Alsamad) showed a 4 cm ulceration, lipidaemia, angina pectoris, hypertension, and fibrosis disrupting the architecture of the mus- unexplained thrombosis of the radial artery in cular fibres, and thrombosis of the vessels with 1986. There was no history ofthrombosis in the mild to moderate recanalisation. There was no family. Drugs taken by the patient included: haematoma. The patient made an uneventful fenofibrate, nifedipin, and bisoprolol. Clinical recovery. Heparin therapy was stopped and findings included hypogastric pain, vomiting, replaced by coumarin. No relapse was seen at blood per anum, and fever (39'C). The the last follow up visit at the end of 1993. abdomen was tender to examination without guarding. The white blood count showed leuco- cytosis and transient hyperthrombocytaemia Case report 2 (570 000/,u). Serum lipase was 3.5 times A 46 year old man was admitted to hospital in normal, while amylase was normal. Ultra- September 1991 for acute abdominal pain. sonography, computed tomography, upper This patient had taken aspirin for a toothache gastrointestinal endoscopy, colonoscopy, and several days previously. There was no history of barium gastroduodenal follow through were thrombosis in the family. Periumbilical pain normal. As pain persisted, repeat ultrasono- was associated with dark red blood per anum. graphy was performed four months later and The abdomen was tender to examination but showed portal vein thrombosis. Intestinal without guarding. The white blood count angiograms showed thrombosis of the splenic showed neutrophil polymorphonucleosis. and mesenteric veins as well. The pancreas was http://gut.bmj.com/ Antral and bulbar erosions were found normal on computed tomography and upon upper gastrointestinal endoscopy and endosonography. Two months later he had disappeared after antisecretory treatment. abdominal pain consistent with Koenig's syn- Colonoscopy and ultrasonography were non- drome. A barium swallow with follow through contributive. As abdominal pain persisted, an showed a short jejunal stricture (2 cm), associ- exploratory laparotomy was performned on ated with proximal dilatation (Fig 2). Distended on September 28, 2021 by guest. Protected copyright. 12 November 199 1. A 2 cm stricture was found intestinal loops were found on laparotomy and on the ileum, 20 cm from the valvule of Bauhin, thought to be caused by a stricture of ischaemic attached to the bladder by a band. Histo- origin. Distant from the stricture, a peritoneal pathological examination showed an ulceration band was found, which was resected along with with granulomatous inflammatory infiltrate, the stricture. Histopathological examination without visible thrombosis. In August 1992, showed a non-ulcerated stenosis with non- repeat laparotomy was performed for intestinal specific inflammatory infiltrate. In submucosa obstruction associated with guarding. A 30 cm and mesentere, vein walls were thickened by segment of infarcted ileum, thought to be caused by venous thrombosis, was resected. TABLE II Haematological investigations There were no bands and the small and large Cases TABLE i Abdominal investigations 1 2 3 Cases Bone marrow culture* N N N 1 2 3 Platelets N N Nt Protein S NN N US Heterogeneous pancreatic head N N Protein C N N N CT Heterogeneous pancreatic head N N AT III N N N MRI Heterogeneous pancreatic head ND ND PT, APT N N N Endosonography Heterogeneous pancreatic head N N Factors II, V, VII, and X N N N ERCP N N ND Fibrinogen N N N Gastroscopy Ulcerations* Ulcerations* Varix Plasminogen ND N N Colonoscopy 8 mm polyp N N Euglobulin lysis ND N N Angiograms Nt ND Nt After venous occlusion ND NN Ham-Dacie test N ND N Amylasaemia N N N Circulating anticoagulants N N N Lipasaemia ND N 3-5 N Antiphospholipid antibodies +1 N N Laparotomy N N N Anticardiolipin antibodies
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