Yee-Huang Ku¹ and Wen-Liang Yu^2,3
1Division of Infectious Disease, Department of Internal Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
²Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan City, Taiwan
³Department of Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan

Part of the book: Advances in Health and Disease. Volume 62

Abstract

Superior mesenteric venous (SMV) thrombosis is an infrequent thrombotic event of hypercoagulable states that can cause intestinal ischemia, hemorrhage, or infarction. Despite severe consequences, SMV thrombosis often presents with nonspecific clinical features, including abdominal pain, distension, diarrhea, nausea, vomiting, intestinal obstruction, and bloody stool. SMV thrombosis may cause portal hypertension and its associated symptoms like intractable ascites of profuse production. Laboratory data may include elevation of hepatic enzyme, amylase, or lipase levels. SMV thrombosis is associated with a specific etiology (malignancy, thrombophilia, inflammatory bowel disease, intra-abdominal infection, or surgery). Other conditions or diseases such as pregnancy, puerperium, influenza, coronavirus disease-2019, and vaccine-induced immune thrombocytopenia are associated with thrombosis formation in various vessels, including SMV. Computed tomography (CT) imaging in the venous phase is considered the most reliable diagnostic method of choice. CT imaging may find acute thrombi present in SMV associated with submucosal edema in some intestinal loops. Management strategies are complicated by an underlying prothrombotic state and an increased risk of bleeding. SMV thrombosis can be reversed by effective anticoagulation. Prompt transcatheter thrombolysis can achieve early SMV revascularization. Early diagnosis prevents anticoagulation with continuous intravenous infusion of unfractionated heparin preventing subsequent consequences. Open laparotomy with mesenteric revascularization and resection of necrotic bowel has been considered the gold standard of care. Despite systemic anticoagulation therapy with intravenous heparin, the decision of an exploratory open thrombectomy could be made for patient deterioration clinically. The mortality rate among patients with acute SMV thrombosis ranges from less than 10% to 50%, depending on disease severity requiring surgical intervention. Negative predictors of survival include a higher Charlson comorbidity index and malignancy. Earlier diagnosis by the widespread use of CT scanning and aggressive treatment with anticoagulation may prevent progression to gangrenous bowel and lower mortality rates.

Keywords: anticoagulation, mesenteric, thrombectomy, thrombolysis, thrombosis

References

[1] Scott JA, Barry PJ, Jones AM, Athwal VS. Management of superior mesenteric
venous thrombus in cystic fibrosis related liver disease. Paediatr Respir Rev., 2020,
35, 106-108.
[2] Hatoum OA, Spinelli KS, Abu-Hajir M, Attila T, Franco J, Otterson MF, Telford
GL, Binion DG. Mesenteric venous thrombosis in inflammatory bowel disease. J
Clin Gastroenterol., 2005, 39, 27-31.
[3] Morasch MD, Ebaugh JL, Chiou AC, Matsumura JS, Pearce WH, Yao JS.
Mesenteric venous thrombosis: a changing clinical entity. J Vasc Surg., 2001, 34,
680-684.
[4] Guan X, Huang L, Li L. Acute mesenteric venous thrombosis in a pregnant woman
at 35 weeks of gestation: a case report and review of the literature. BMC Pregnancy
Childbirth., 2018, 18, 487.
[5] Vekariya P, Daneti D, Senthamizhselvan K, Sureshkumar S, Mohan P. Acute
intestinal obstruction as an initial presentation of mesenteric venous thrombosis.
Cureus, 2021, 13, e15652.
[6] Acosta S. Epidemiology of mesenteric vascular disease: clinical implications. Semin
Vasc Surg., 2010, 23, 4-8.
[7] Andersson R, Pärsson H, Isaksson B, Norgren L. Acute intestinal ischemia. A 14-
year retrospective investigation. Acta Chir Scand., 1984, 50, 217-221.
[8] Tsai CJ, Kuo YC, Chen PC, Wu CS. The spectrum of acute intestinal vascular
failure: a collective review of 43 cases in Taiwan. Br J Clin Pract., 1990, 44, 603-608.
[9] Feldman ZM, Wang LJ, Chou EL, Latz CA, Sumpio BJ, Eagleton MJ, Conrad MF.
Venous mesenteric ischemia carries high procedural burden and elevated mortality
in patients with severe presentation. J Vasc Surg Venous Lymphat Disord., 2021, 9,
1479-1487.
[10] Walsh DS, Crombleholme TM. Superior mesenteric venous thrombosis in
malrotation with chronic volvulus. J Pediatr Surg., 2000, 35, 753-755.
[11] Paraskeva P, Akoh JA. Small bowel stricture as a late sequela of superior mesenteric
vein thrombosis. Int J Surg Case Rep., 2015, 6C, 118-121.
[12] Schmutz GR, Benko A, Billiard JS, Fournier L, Péron JM, Fisch-Ponsot C.
Computed tomography of superior mesenteric vein thrombosis following
appendectomy. Abdom Imaging., 1998, 23, 563-567.
[13] Rackoff A, Shores N, Willner I. Mesenteric venous thrombosis in a patient with
pancreatitis and protein C deficiency. South Med J., 2005, 98, 232-234.
[14] Osti NP, Sah DN, Bhandari RS. Successful medical management of acute
mesenteric ischemia due to superior mesenteric and portal vein thrombosis in a 27-
year-old man with protein S deficiency: a case report. J Med Case Rep., 2017, 9, 11, 315.
[15] Priyadarshi RN, Anand U, Kumar R, Thakur SK, Bhadani PP, Kumar P. Ischemic
jejunal stricture in patients with extrahepatic portal vein obstruction. Indian J
Gastroenterol., 2021, 40, 82-87.
[16] Kato T, Morita T, Fujita M, Miyasaka Y, Senmaru N, Hiraoka K, Horita S, Kondo
S, Kato H. Ischemic stricture of the small intestine associated with acute pancreatitis.
Int J Pancreatol., 1998, 24, 237-242.
[17] Samoyedny A, Sajja S, Ratnasekera A. Idiopathic acute mesenteric venous
thrombosis causing ischemic enteritis: A case report. Int J Surg Case Rep., 2020, 74,
247-250.
[18] Kim HK, Hwang D, Park S, Lee JM, Huh S. Treatment outcomes and risk factors
for bowel infarction in patients with acute superior mesenteric venous thrombosis.
J Vasc Surg Venous Lymphat Disord., 2017, 5, 638-646.
[19] Kumar S, Kamath PS. Acute superior mesenteric venous thrombosis: one disease or
two? Am J Gastroenterol., 2003, 98, 1299-1304.
[20] Rharrit D, Harmouche H, Baroudi S, Mezalek ZT, Adnaoui M, Hassani A, Maaouni
A. Protein C deficiency and mesenteric venous thrombosis. Can J Surg., 2009, 52,
E35-37.
[21] Sasaki Y, Yamada M, Hori T, Yamamoto H, Harada H, Yamamoto M, Yazawa T,
Sasaki B, Tani M, Sato A, Katsura H, Kamada Y, Tani R, Aoyama R, Zaima M.
Acute intestinal infarction caused by initially unexplained splanchnic venous
thromboses in a patient with protein C deficiency: A thought-provoking emergency
case. Int J Surg Case Rep., 2021, 79, 390-393.
[22] Mitani M, Kuwabara Y, Kawamura H, Sato A, Hattori K, Fujii Y. Mesenteric
venous thrombosis associated with protein C deficiency. J Gastroenterol., 1999, 34,
387-389.
[23] Rawla P, Pradeep Raj J, Thandra KC, Bandaru SS. Superior mesenteric vein
thrombosis in a patient on oral contraceptive pills. Gastroenterology Res., 2017, 10,
380-382.
[24] Giannos A, Stavrou S, Goumalatsos N, Fragkoulidis G, Chra E, Argiropoulos D,
Loutradis D, Drakakis P. Mesenteric cysts and mesenteric venous thrombosis
leading to intestinal necrosis in pregnancy managed with laparotomy: a case report
and review of the literature. J Med Case Rep., 2017, 11, 184.
[25] Lin H, Lin CC, Huang WT. Idiopathic superior mesenteric vein thrombosis resulting
in small bowel ischemia in a pregnant woman. Case Rep Obstet Gynecol., 2011,
2011, 687250.
[26] Zhao Q, Liu Y, Li Y, Liu D. Portal system thrombosis in puerperium: a case report
and literature review. Clin Res Hepatol Gastroenterol., 2013, 37, 501-506.
[27] Chan CM, Chen WL, Chen JH, Wu YL, Huang CC. Pregnancy-induced acute
intestinal infarction in a woman with chronic idiopathic mesenteric vein thrombosis
under regular anticoagulation treatment. Med Princ Pract., 2009, 18, 422-424.
[28] Oh GM, Jung K, Kim JH, Kim SE, Moon W, Park MI, Park SJ. Superior mesenteric
vein thrombosis induced by influenza infection: A case report. World J Clin Cases,
2020, 8, 4193-4199.
[29] Ebrahiminik H, Nikpour S, Yazdi HR, Mohammadi A, Mirza-Aghazadeh-Attari M.
Successful vascular interventional management of superior mesenteric vein
thrombosis in a patient with COVID-19: A case report and review of literature.
Radiol Case Rep., 2021, 16, 1539-1542.
[30] Gündoğdu E, Cihan Ç, Aydın N, Demirayak D, Özakyol A, Kebapçı M. A case of
intestinal perforation associated with mesenteric thrombosis due to post-COVID-19
syndrome. Curr Med Imaging., 2022, https://doi.org/10.2174/1573405618999220209113933.
[31] Kheyrandish S, Rastgar A, Arab-Zozani M, Sarab GA. Portal vein thrombosis might
develop by COVID-19 infection or vaccination: A systematic review of case-report
studies. Front Med (Lausanne). 2021, 8, 794599.
[32] Fanni D, Saba L, Demontis R, Gerosa C, Chighine A, Nioi M, Suri JS, Ravarino A,
Cau F, Barcellona D, Botta MC, Porcu M, Scano A, Coghe F, Orrù G, Van Eyken
P, Gibo Y, La Nasa G, D’aloja E, Marongiu F, Faa G. Vaccine-induced severe
thrombotic thrombocytopenia following COVID-19 vaccination: a report of an
autoptic case and review of the literature. Eur Rev Med Pharmacol Sci., 2021, 25,
5063-5069.
[33] Umbrello M, Brena N, Vercelli R, Foa RA, Femia M, Rossi U, Podda GM,
Cortellaro F, Muttini S. Successful treatment of acute spleno-porto-mesenteric vein
thrombosis after ChAdOx1 nCoV-19 vaccine. A case report. J Crit Care, 2021, 65,
72-75.
[34] Corica B, Cacciani A, Cangemi R, Visentini M, Recchia F, Grillo R, Vano M,
Sperduti N, Cincione A, Buoninfante G, Pulcinelli F, Chistolini A, De Santis A,
Flego D, Romiti GF, Basili S, Stefanini L. Clinical course, management, and platelet
activity assessment of splanchnic VITT: A case report. Thromb Res., 2021, 208, 14-17.
[35] Elberry MH, Abdelgawad HAH, Hamdallah A, Abdella WS, Ahmed AS, Ghaith
HS, Negida A. A systematic review of vaccine-induced thrombotic
thrombocytopenia in individuals who received COVID-19 adenoviral-vector-based
vaccines. J Thromb Thrombolysis, 2022, 1-26. https://doi.org/10.1007/s11239-021-02626-w.
[36] Ceccarelli M, Venanzi Rullo E, Nunnari G. Risk factors of venous thrombo embolism
during cytomegalovirus infection in immunocompetent individuals. A
systematic review. Eur J Clin Microbiol Infect Dis., 2018, 37, 381-390.
[37] Puccia F, Lombardo V, Giannitrapani L, Licata A, Mazzola G, Soresi M. Case
report: acute portal vein thrombosis associated with acute cytomegalovirus infection
in an immunocompetent adult. J Ultrasound., 2017, 20, 161-165.
[38] Benoist S, Laisné MJ, Joly F, Boudiaf M, Panis Y, Valleur P. Cytomegalovirus
infection as a cause of acute superior mesenteric vein thrombosis with jejunal
infarction. Surgery, 2003, 133, 222-223.
[39] Amitrano L, Guardascione MA, Scaglione M, Menchise A, Romano L, Balzano A.
Acute portal and mesenteric thrombosis: unusual presentation of cytomegalovirus
infection. Eur J Gastroenterol Hepatol., 2006, 18, 443-445.
[40] Zamani F, Amiri A, Mohit M, Zolfaghari M, Jalaeefar A, Ranjbar M, Shakeri R.
CMV infection in a pregnant woman complicated by toxic megacolon and
mesenteric vein thrombosis. Turk J Gastroenterol., 2009, 20, 234-235.
[41] Nishimura N, Ueda N, Kawaguchi T, Shirahama T, Himeji D, Yamanaka A. A case
of multiple venous thromboses associated with acute cytomegalovirus infection.
Kansenshogaku Zasshi., The Journal of the Japanese Association for Infectious
Diseases. 2017, 91, 20-24. [Japanese].
[42] Vael A, Degryse H, Bracke P. Acute cytomegalovirus infection as a rare cause of
portal vein thrombosis with small bowel infarction in an immunocompetent patient.
J Belg Soc Radiol., 2017, 101, 16.
[43] Zezos P, Kouklakis G, Saibil F. Inflammatory bowel disease and thromboembolism.
World J Gastroenterol., 2014, 20, 13863-13878.
[44] Naïk Vietti N, Vietti Violi N, Schoepfer AM, Fournier N, Guiu B, Bize P, Denys A;
Swiss Inflammatory Bowel Disease Cohort Study Group. Prevalence and clinical
importance of mesenteric venous thrombosis in the Swiss Inflammatory Bowel
Disease Cohort. AJR Am J Roentgenol., 2014, 203, 62-69.
[45] Arora Z, Wu X, Navaneethan U, Shen B. Non-surgical porto-mesenteric vein
thrombosis is associated with worse long-term outcomes in inflammatory bowel
diseases. Gastroenterol Rep (Oxf.), 2016, 4, 210-215.
[46] Lin H, Bai Z, Meng F, Wu Y, Luo L, Shukla A, Yoshida EM, Guo X, Qi X.
Epidemiology and risk factors of portal venous system thrombosis in patients with
inflammatory bowel disease: A systematic review and meta-analysis. Front Med
(Lausanne), 2022, 8, 744505.
[47] Levartovsky A, Barash Y, Ben-Horin S, Ungar B, Klang E, Soffer S, Kopylov U.
Thromboprophylaxis for hospitalized patients with inflammatory bowel disease-Are
we there yet? J Clin Med., 2020, 9, 2753.
[48] Kopylov U, Amitai MM, Lubetsky A, Eliakim R, Chowers Y, Ben-Horin S. Clinical
and radiographic presentation of superior mesenteric vein thrombosis in Crohn’s
disease: a single center experience. J Crohns Colitis., 2012, 6, 543-549.
[49] Ito S, Higashiyama M, Horiuchi K, Mizoguchi A, Soga S, Tanemoto R, Nishii S,
Terada H, Wada A, Sugihara N, Hanawa Y, Furuhashi H, Takajo T, Shirakabe K,
Watanabe C, Komoto S, Tomita K, Nagao S, Shinozaki M, Nakagawa A, Kubota
M, Miyagishima D, Gotoh N, Miura S, Ueno H, Hokari R. Atypical clinical
presentation of Crohn’s disease with superior mesenteric vein obstruction and
protein-losing enteropathy. Intern Med., 2019, 58, 369-374.
[50] Kanellopoulou T, Alexopoulou A, Theodossiades G, Koskinas J, Archimandritis AJ.
Pylephlebitis: an overview of non-cirrhotic cases and factors related to outcome. J
Infect Dis., 2010, 42, 804-811.
[51] Gad A, Hindi Z, Zahoor T, Zock RZÀ. Superior mesenteric venous thrombosis
complicating acute appendicitis: A case report. Medicine (Baltimore), 2018, 97,
e11168.
[52] Adibimehr A, SeyedAlinaghi S, Nourian A, Mehrabi Z, Moslemi R. Superior
mesenteric venous (SMV) thrombosis accompanied with appendicitis in a patient
with primary diagnosis of typhoid fever. Infect Disord Drug Targets, 2021, 21, 634-636.
[53] Yoon SH, Lee MJ, Jung SY, Ho IG, Kim MK. Mesenteric venous thrombosis as a
complication of appendicitis in an adolescent: A case report and literature review.
Medicine (Baltimore), 2019, 98, e18002.
[54] Seo KI, Kim SE, Park MI, Park SJ, Moon W, Kim JH, Jung K, Park JG. Recurrent
abdominal pain after laparoscopic appendectomy. Korean J Gastroenterol., 2017,
69, 187-190.
[55] Lole Harris BH, Walsh JL, Nazir SA. Super-mesenteric-vein-expia-thrombosis, the
clinical sequelae can be quite atrocious. Int J Adolesc Med Health, 2016, 28, 445-449.
[56] Stitzenberg KB, Piehl MD, Monahan PE, Phillips JD. Interval laparoscopic
appendectomy for appendicitis complicated by pylephlebitis. JSLS., 2006, 10, 108-113.
[57] Parmeshwar Ramesh J, Sanjay C, Udgirkar S, Sujit N, Prasanta D, Ammar M, Partha
D, Shubham J, Thanage R, Pravin R, Qais C. Multiple extra-splanchnic venous
thromboses – an unusual vascular complication of acute pancreatitis. Clin Pract.,
2020, 10, 1226.
[58] Junare PR, Udgirkar S, Nair S, Debnath P, Jain S, Modi A, Rathi P, Rane S,
Contractor Q. Splanchnic venous thrombosis in acute pancreatitis: does
anticoagulation affect outcome? Gastroenterology Res., 2020, 13, 25-31.
[59] Okino Y, Kiyosue H, Mori H, Komatsu E, Matsumoto S, Yamada Y, Suzuki K,
Tomonari K. Root of the small-bowel mesentery: correlative anatomy and CT
features of pathologic conditions. Radiographics, 2001, 21, 1475-1490.
[60] Wang MQ, Lin HY, Guo LP, Liu FY, Duan F, Wang ZJ. Acute extensive portal and
mesenteric venous thrombosis after splenectomy: treated by interventional
thrombolysis with transjugular approach. World J Gastroenterol., 2009, 15, 3038-3045.
[61] Akabane S, Mukai S, Egi H, Adachi T, Kochi M, Sato K, Sumi Y, Nakashima I,
Taguchi K, Sada H, Ishikawa A, Yasui W, Ohdan H. A case of ascending colon
cancer accompanied with tumor thrombosis in the superior mesenteric vein treated
with right hemicolectomy and greater saphenous vein grafting. Int J Surg Case Rep.,
2018, 51, 358-363.
[62] Kim SE, Lee SJ, Cha JY, Yi SW, Kim TS, Cho IL, Kwak JY, Oh KH. Ascending
colon cancer with pathologically confirmed tumor thrombosis of superior
mesenteric vein: A case report. Clin Endosc., 2019, 52, 506-509.
[63] Fujii Y, Kobayashi K, Kimura S, Uehara S, Takiguchi S. Ascending colon cancer
accompanied by tumor thrombosis in the superior mesenteric vein: A case report.
Int J Surg Case Rep., 2020, 73, 239-243.
[64] Emekli E, Gündoğdu E. Computed tomography evaluation of early post-operative
complications of the Whipple procedure. Pol J Radiol., 2020, 85, e104-e109.
[65] Flis V, Potrc S, Kobilica N, Ivanecz A. Pancreaticoduodenectomy for ductal
adenocarcinoma of the pancreatic head with venous resection. Radiol Oncol., 2016,
50, 321-328.
[66] Jouffret L, Guilbaud T, Turrini O, Delpero JR. Pancreaticoduodenectomy with
combined superior mesenteric vein resection without reconstruction is possible: A
case report and review of the literature. World J Clin Cases, 2018, 6, 214-218.
[67] Boone BA, Zenati MS, Rieser C, Hamad A, Al-Abbas A, Zureikat AH, Hogg ME,
Neal MD, Zeh HJ 3rd. Risk of venous thromboembolism for patients with pancreatic
ductal adenocarcinoma undergoing preoperative chemotherapy followed by surgical
resection. Ann Surg Oncol., 2019, 26, 1503-1511.
[68] Labori KJ, Kleive D, Khan A, Farnes I, Fosby B, Line PD. Graft type for superior
mesenteric and portal vein reconstruction in pancreatic surgery – A systematic
review. HPB (Oxford), 2021, 23, 483-494.
[69] Lim KH, Jang J, Yoon HY, Park J. Acute superior mesenteric vein thrombosis
associated with abdominal trauma: A rare case report and literature review. Medicine
(Baltimore), 2017, 96, e8863.
[70] Ahmad MSM, Iqbal MR, Refson JS. Acute mesenteric ischaemia due to superior
mesenteric vein (SMV) thrombosis. BMJ Case Rep., 2021, 14, e239110.
[71] Kim HS, Patra A, Khan J, Arepally A, Streiff MB. Transhepatic catheter-directed
thrombectomy and thrombolysis of acute superior mesenteric venous thrombosis. J
Vasc Interv Radiol., 2005, 16, 1685-1691.
[72] Sun SL, Wang XY, Chu CN, Liu BC, Li QR, Ding WW. Predictors of irreversible
intestinal resection in patients with acute mesenteric venous thrombosis. World J
Gastroenterol., 2020, 26, 3625-3637.
[73] Rabuffi P, Vagnarelli S, Bruni A, Antonuccio G, Ambrogi C. Percutaneous
pharmaco-mechanical thrombectomy of acute symptomatic superior mesenteric
vein thrombosis. Cardiovasc Intervent Radiol., 2020, 43, 46-54.
[74] Alnahhal K, Toskich BB, Nussbaum S, Li Z, Erben Y, Hakaim AG, Farres H.
Superior mesenteric venous thrombosis: Endovascular management and outcomes.
World J Clin Cases, 2022, 10, 217-226.
[75] Wijaya R, Ng JH, See AH, Kum SW. Open thrombectomy for primary acute
mesentericoportal venous thrombosis–should it be done? Ann Vasc Surg., 2015, 29,
1454.e21-5.
[76] Lim S, Halandras PM, Bechara C, Aulivola B, Crisostomo P. Contemporary
management of acute mesenteric ischemia in the endovascular era. Vasc
Endovascular Surg., 2019, 53, 42-50.
[77] Hiranuma W, Shimizu T, Takeda M, Matsuoka T, Minagawa T, Fukutomi T, Ohara
M, Kawamoto S. A case of superior mesenteric venous thrombosis managed by
thrombectomy without bowel resection. Ann Vasc Dis., 2020, 13, 447-449.
[78] Yokota Y, Yoshioka T, Senoh M, Sunami K. Successful intravenous administration
of argatroban in the management of heparin-resistant and surgery-resistant
mesenteric vein thrombosis. BMJ Case Rep., 2019, 12, e228427.
[79] Raja K, Jacob M, Asthana S. Portal vein thrombosis in cirrhosis. J Clin Exp
Hepatol., 2014, 4, 320-331.
[80] Chawla YK, Bodh V. Portal vein thrombosis. J Clin Exp Hepatol., 2015, 5, 22-40.
[81] Kawagishi N. HCC with portal vein tumor thrombosis: how to manage? Hepatol
Int., 2020, 14, 609-611.
[82] Inderbitzi R, Wagner HE, Seiler C, Stirnemann P, Gertsch P. Acute mesenteric
ischaemia. Eur J Surg., 1992, 158, 123-126.