IJSS Journal of Surgery

Superior Mesenteric Vein Thrombosis as a Complication of Severe Appendicitis

Abinash Hazarika, Santhosh Kumar, Partha Pratim Bora

Introduction

Superior mesenteric vein (SMV) thrombosis caused by appendicitis is a very rare entity in the recent times due to improved high-quality imaging techniques and use of broad-spectrum antibiotics.1,2 It is important to be aware of the possibility of SMV thrombosis while managing patients with appendicitis as the mortality rate in SMV thrombosis is associated with intra-abdominal infection with SMV thrombosis possibly causing intestinal edema, congestion, and necrosis.3,4

A 51-year-old male patient presented with the complaint of pain abdomen since 15 days, fever since 12 days and loose stools since 1-day.

On clinical examination, the patient was febrile and per abdomen revealed diffuse tenderness and a palpable mass in right iliac fossa.

Investigations revealed elevated total leucocyte count (14,100) with 70% neutrophils. Ultra Sonograph of abdomen and pelvis revealed minimum G.B sludge and was inconclusive. Contrast enhanced computed tomography (CECT) abdomen was done for further evaluation which revealed complete thrombosis in the main portal vein and its right and left branches, SMV and most of its most of its tributaries, thickened small bowel loops predominantly jejunal loops showing ‘TARGET’ sign likely representing an early sign of bowel wall ischemia, a distended tubular structure with enhancing wall in the right iliac fossa with adjacent fat stranding and minimal free fluid, likely representing changes of acute appendicitis and mild ascites (Figures 1 and 2). As the patient condition deteriorated an exploratory laparotomy was performed. Laparotomy revealed that the peritoneum was filled with fluid and fluid collection in the right iliac fossa. Appendix was retrocecal and gangrenous pus oozing from tip of the appendix, the appendix was ligated and dissected (Figures 3 and 4). Small bowel was traced, reveals edematous and dark in color jejunum which is approximately around 15 cm and was 30 cm from DJ flexure. The mesentery was thickened with multiple hemorrhagic patches. As. mesenteric blood supply to the jejunum was intact, so no resection was done and to planned to manage conservatively. Peritoneal toileting was done; following which Injection Enoxaparin 60 mg subcutaneously was given as intraoperative dose, and followed for 10 days. Oral warfarin started on 3rd day and was advised for 3 months.

Figure 1
Computed tomography showing occlusion of the superior mesenteric vein by a thrombus
Figure 2
Computed tomography showing patent superior mesenteric vein without a thrombus
Figure 3
Intraoperative picture suggesting superior mesenteric vein thrombosis
Figure 4
Appendicectomized specimen

The histopathological examination also confirmed about appendicitis (Figure 5). Post laparotomy his condition improved, clinical symptoms slowly normalized, and total counts normalized within few day. CECT done again after around 45 days post laparotomy, which revealed decrease in thrombosis and recanalization of the tributaries in the portal vein and SMV.

Figure 5
Histopathological picture showing appendicitis
Points to Ponder
  • SMV thrombosis rare complication due to appendicitis. It can be treated successfully with emergency appendicectomy, broad-spectrum antibiotics, and anticoagulation therapy

  • About 80% of the cases reported are due to some secondary causes, either because of the deformed coagulation system (polycythemia vera, protein C deficiency, protein S deficiency, and antithrombin III deficiency) or due to any inflammatory causes (appendicitis, diverticulitis, cholecystitis, pancreatitis, and pelvic inflammatory disease

Authors' information

1, 2,2

Abinash Hazarika1, K Santhosh Kumarr2, Partha Pratim Bora 2

1Professor, Department of General Surgery, Adichunchanagiri Institute of Medical Sciences, Mandya, Karnataka, India 2Post Graduate Student, Department of General Surgery, Adichunachangiri Institute of Medical Sciences, Mandya, Karnataka, India

References

  • Baril N, Wren S, Radin R, Ralls P, Stain S. The role of anticoagulation in pylephlebitis. Am J Surg 1996;172:449-52.
  • Nishimori H, Ezoe E, Ura H, Imaizumi H, Meguro M, Furuhata T, et al. Septic thrombophlebitis of the portal and superior mesenteric veins as a complication of appendicitis: Report of a case. Surg Today 2004;34:173-6.
  • Plemmons RM, Dooley DP, Longfield RN. Septic thrombophlebitis of the portal vein (pylephlebitis): Diagnosis and management in the modern era. Clin Infect Dis 1995;21:1114-20.
  • Singh P, Yadav N, Visvalingam V, Indaram A, Bank S. Pylephlebitis – Diagnosis and management. Am J Gastroenterol 2001;96:1312-3.