Mesenteric Venous Thrombosis Treatment & Management

  • Author: Deron J Tessier, MD; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Jan 6, 2012
 

Medical Therapy

  • The goals of the initial treatment of venous thrombosis are defining the underlying cause of the patient's hypercoagulable state and treating it appropriately.[2]
  • Patients with polycythemia should undergo phlebotomy, while those with clotting abnormalities should receive anticoagulation therapy with heparin.
  • After achieving appropriate anticoagulation, start patients on long-term warfarin.
  • Lytic therapy with urokinase, streptokinase, or tissue plasminogen activator has been found to be beneficial in some cases. Mechanical transhepatic thrombectomy has been described in one patient.[12]
  • Other supportive measures, such as nasogastric decompression, fluid resuscitation, and bowel rest, should be instituted.
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Surgical Therapy

  • Surgery is required only in patients with signs of bowel infarction or peritonitis.[2]
  • When laparotomy reveals acute venous thrombosis, surgically remove the involved bowel and reanastomose the remaining bowel.
  • Direct venous surgery to remove the clot is usually unsuccessful and is best reserved for patients with portal or superior mesenteric vein involvement.
  • Reports of diagnostic laparoscopy in patients with venous thrombosis suggest this modality may have some use in preventing fruitless laparotomies in these patients; however, the decreased mesenteric blood flow that occurs with laparoscopy may worsen bowel ischemia.
  • Patients with severe intestinal loss due to mesenteric venous thrombosis may be considered for intestinal transplantation in specialized centers.
  • Seriously consider a second-look laparotomy, especially in patients with significant bowel involvement, to minimize the amount of bowel loss.
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Preoperative Details

  • Immediately replete fluids in patients with acute ischemia, and correct any acid-base abnormalities; then, operate without delay.
  • Because of the massive amount of blood lost from the circulatory system to the bowel, provide patients with blood transfusions without hesitation. Type and crossmatch 4 units of packed red blood cells before surgery.
  • Start all patients on broad-spectrum antibiotic therapy before the operation.
  • Immediately begin anticoagulation therapy.
  • Vasodilators have not proven effective in the treatment of venous thrombosis.
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Intraoperative Details

  • Establish viability during direct visualization of the bowel. Look for peristalsis, and observe the color of the bowel. Hemorrhagic, edematous bowel suggests visceral thrombosis as the cause of ischemia.
  • One gram of intravenous fluorescein followed by bowel examination under Wood lamp illumination can delineate poorly perfused bowel. Intraoperative Doppler studies are not as effective as fluorescein studies in determining venous thrombosis.
  • Anticoagulation therapy with intravenous heparin should be continued intraoperatively.
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Postoperative Details

  • Postoperative care includes close monitoring of blood pressure and hemoglobin parameters to evaluate for sepsis or hemorrhage.
  • Patients should have heparin anticoagulation continued postoperatively to reduce thrombotic events. Studies have shown that 60% of cases of rethrombosis of the mesenteric vein occur at the site of reanastomosis, probably because of local thrombotic factors. This finding demonstrates the importance of maintaining the patient on postoperative heparin therapy.[13]
  • Patients require a workup for a hypercoagulable state if this was not accomplished preoperatively.
  • A patient can be expected to have a postoperative ileus due to bowel reperfusion.
  • Unlike patients with arterial ischemia, patients with venous thrombosis do not require a second-look laparotomy unless progression of the disease is possible, which typically occurs in 40% of patients.
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Follow-up

  • Because of the high incidence of concomitant vascular disease, patients require close monitoring.
  • Perform routine evaluations of the PT, aPTT, and international normalized ratio to ensure the adequacy of anticoagulation therapy.
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Complications

Because patients with venous thrombosis are typically in a hypercoagulable state, the incidence of deep venous thrombosis is increased. Proper anticoagulation therapy and liberal use of sequential compression stockings can help prevent this postoperative complication.

Patients should have a Swan-Ganz catheter kept in place postoperatively to monitor cardiac and pulmonary status.

Because patients become acutely hypovolemic, acute renal failure may occur. Keeping the patient well hydrated and administering mannitol before the aorta is cross-clamped can prevent acute renal failure.

Inform patients of other possible complications, including bleeding, infection, bowel infarction, and prolonged ileus.

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Outcome and Prognosis

Acute venous thrombosis has a 30% mortality rate with a 25% recurrence rate without anticoagulant therapy. Anticoagulant therapy combined with surgery is associated with the lowest recurrence rate (~3-5%). Patients presenting with peritonitis and infarcted bowel have a prolonged and complicated course. Of all etiologies of mesenteric ischemia, venous thrombosis carries the best prognosis.[14] Survival has improved over the last 4 decades.

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Contributor Information and Disclosures
Author

Deron J Tessier, MD  Staff Surgeon, Kaiser Permanente Medical Center, Fontana, CA

Deron J Tessier, MD is a member of the following medical societies: American College of Surgeons and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Alex Jacocks, MD  Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David L Morris, MD, PhD, FRACS  Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

Additional Contributors

The editors of eMedicine would like to thank Russell A Williams, MBBS, for his previous contributions to this article.

References

  1. Harnik IG, Brandt LJ. Mesenteric venous thrombosis. Vasc Med. Oct 2010;15(5):407-18. [Medline].

  2. Alvi AR, Khan S, Niazi SK, et al. Acute mesenteric venous thrombosis: improved outcome with early diagnosis and prompt anticoagulation therapy. Int J Surg. Jun 2009;7(3):210-3. [Medline].

  3. Ji M, Yoon SN, Lee W, Jang S, Park SH, Kim DY, et al. Protein S deficiency with a PROS1 gene mutation in a patient presenting with mesenteric venous thrombosis following total colectomy. Blood Coagul Fibrinolysis. Oct 2011;22(7):619-21. [Medline].

  4. Wang MQ, Lin HY, Guo LP, et al. Acute extensive portal and mesenteric venous thrombosis after splenectomy: treated by interventional thrombolysis with transjugular approach. World J Gastroenterol. Jun 28 2009;15(24):3038-45. [Medline]. [Full Text].

  5. Stamou KM, Toutouzas KG, Kekis PB, et al. Prospective study of the incidence and risk factors of postsplenectomy thrombosis of the portal, mesenteric, and splenic veins. Arch Surg. Jul 2006;141(7):663-9. [Medline]. [Full Text].

  6. Wang MQ, Liu FY, Duan F, Wang ZJ, Song P, Fan QS. Acute symptomatic mesenteric venous thrombosis: treatment by catheter-directed thrombolysis with transjugular intrahepatic route. Abdom Imaging. Aug 2011;36(4):390-8. [Medline]. [Full Text].

  7. James AW, Rabl C, Westphalen AC, et al. Portomesenteric venous thrombosis after laparoscopic surgery: a systematic literature review. Arch Surg. Jun 2009;144(6):520-6. [Medline].

  8. Swartz DE, Felix EL. Acute mesenteric venous thrombosis following laparoscopic Roux-en-Y gastric bypass. JSLS. Apr-Jun 2004;8(2):165-9. [Medline].

  9. Abu-Daff S, Abu-Daff N, Al-Shahed M. Mesenteric venous thrombosis and factors associated with mortality: a statistical analysis with five-year follow-up. J Gastrointest Surg. Jul 2009;13(7):1245-50. [Medline].

  10. Barmase M, Kang M, Wig J, Kochhar R, Gupta R, Khandelwal N. Role of multidetector CT angiography in the evaluation of suspected mesenteric ischemia. Eur J Radiol. Dec 2011;80(3):e582-7. [Medline].

  11. Acosta S, Ogren M, Sternby NH. Mesenteric venous thrombosis with transmural intestinal infarction: a population-based study. J Vasc Surg. Jan 2005;41(1):59-63. [Medline].

  12. Takahashi N, Kuroki K, Yanaga K. Percutaneous transhepatic mechanical thrombectomy for acute mesenteric venous thrombosis. J Endovasc Ther. Aug 2005;12(4):508-11. [Medline]. [Full Text].

  13. Thomas RM, Ahmad SA. Management of acute post-operative portal venous thrombosis. J Gastrointest Surg. Jul 7 2009;[Medline].

  14. Schoots IG, Koffeman GI, Legemate DA, et al. Systematic review of survival after acute mesenteric ischaemia according to disease aetiology. Br J Surg. Jan 2004;91(1):17-27. [Medline].

  15. Abdu RA, Zakhour BJ, Dallis DJ. Mesenteric venous thrombosis--1911 to 1984. Surgery. Apr 1987;101(4):383-8. [Medline].

  16. Bradbury MS, Kavanagh PV, Bechtold RE, et al. Mesenteric venous thrombosis: diagnosis and noninvasive imaging. Radiographics. May-Jun 2002;22(3):527-41. [Medline].

  17. Cho YP, Jung SM, Han MS, et al. Role of diagnostic laparoscopy in managing acute mesenteric venous thrombosis. Surg Laparosc Endosc Percutan Tech. Jun 2003;13(3):215-7. [Medline].

  18. Dada FB, Balan AD. Recurrent primary mesenteric venous thrombosis. South Med J. Oct 1987;80(10):1329-30. [Medline].

  19. Eldrup-Jorgensen J, Hawkins RE, Bredenberg CE. Abdominal vascular catastrophes. Surg Clin North Am. Dec 1997;77(6):1305-20. [Medline].

  20. Ellis DJ, Brandt LJ. Mesenteric venous thrombosis. Gastroenterologist. Dec 1994;2(4):293-8. [Medline].

  21. Engelhardt TC, Kerstein MD. Pregnancy and mesenteric venous thrombosis. South Med J. Nov 1989;82(11):1441-3. [Medline].

  22. Espiritu CR, Robinson MJ. The clinical presentation of mesenteric vascular disease. South Med J. Feb 1975;68(2):153-6. [Medline].

  23. Grieshop RJ, Dalsing MC, Cikrit DF, et al. Acute mesenteric venous thrombosis. Revisited in a time of diagnostic clarity. Am Surg. Sep 1991;57(9):573-7; discussion 578. [Medline].

  24. Hassan HA, Raufman JP. Mesenteric venous thrombosis. South Med J. Jun 1999;92(6):558-62. [Medline].

  25. Henao EA, Bohannon WT, Silva MB. Treatment of portal venous thrombosis with selective superior mesenteric artery infusion of recombinant tissue plasminogen activator. J Vasc Surg. Dec 2003;38(6):1411-5. [Medline].

  26. Khodadadi J, Rozencwajg J, Nacasch N, et al. Mesenteric vein thrombosis. The importance of a second-look operation. Arch Surg. Mar 1980;115(3):315-7. [Medline].

  27. Kitchens CS. Evolution of our understanding of the pathophysiology of primary mesenteric venous thrombosis. Am J Surg. Mar 1992;163(3):346-8. [Medline].

  28. Lopera JE, Correa G, Brazzini A, et al. Percutaneous transhepatic treatment of symptomatic mesenteric venous thrombosis. J Vasc Surg. Nov 2002;36(5):1058-61. [Medline].

  29. Matos C, Van Gansbeke D, Zalcman M, et al. Mesenteric vein thrombosis: early CT and US diagnosis and conservative management. Gastrointest Radiol. 1986;11(4):322-5. [Medline].

  30. Nair HT, Muscroft TJ. Idiopathic mesenteric venous thrombosis. Br J Clin Pract. Dec 1990;44(12):651-2. [Medline].

  31. Nishida S, Levi D, Kato T, et al. Ninety-five cases of intestinal transplantation at the University of Miami. J Gastrointest Surg. Mar-Apr 2002;6(2):233-9. [Medline].

  32. Preventza OA, Habib FA, Young SC. Portal vein thrombosis: an unusual complication of laparoscopic cholecystectomy. JSLS. Jan-Mar 2005;9(1):87-90. [Medline].

  33. Rhee RY, Gloviczki P. Mesenteric venous thrombosis. Surg Clin North Am. Apr 1997;77(2):327-38. [Medline].

  34. Roman RJ, Loeb PM. Massive colonic dilatation as initial presentation of mesenteric vein thrombosis. Dig Dis Sci. Mar 1987;32(3):323-6. [Medline].

  35. Train JS, Ross H, Weiss JD, et al. Mesenteric venous thrombosis: successful treatment by intraarterial lytic therapy. J Vasc Interv Radiol. May-Jun 1998;9(3):461-4. [Medline].

 
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Computed tomography (CT) scan demonstrating thrombosis of the superior mesenteric vein.
Computed tomography (CT) scan demonstrating thrombosis of the portal vein.
Computed tomography (CT) scan demonstrating cavernous change of the superior mesenteric vein, a consequence of venous thrombosis.
 
 
 
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