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Internal Medicine
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ACD 10/16/2014JORGE JO KAMIMOTO MD PGY 2 IM
Simulated case presentation
Elderly man that presents to ED for: Intermittent abdominal pain on and off for 1 week associated with
constipation
Usually notices it after eating or drinking
Subjective fever for 24 hours
PMH: CAD, HTN, HLPD, DM II
UTD on colo screening
Vitals:
Bp 125/75 mmHg, Hr 130, RR 18, Temp 101.5 F
Physical exam
No apparent distress
Gi: Soft, tender to deep palpation in epigastrium and RUQ, BS+
Rest of exam is unrevealing
Cbc WNL, BMP shows slight AKI and slight metabolic anion gap acidosis.
UA and LFTs again unremarkable
What is your differential diagnosis?
The ED isn’t sure, but worried about a lot of things that show up on CT, so they get a CT abdomen/pelvis with IV and oral contrast. It shows….
…thrombus noted in the superior mesenteric vein extending into the portal veins with some subsegmental occlusion noted. There is a small foci of air associated with thrombus. No pneumoatosis and no free air…
What should you do next?
Mesenteric vein thrombosis
JORGE JO KAMIMOTO MD PGY 2 IM
Pathogenesis Primary vs Secondary
Secondary in 75% of cases
Conditions associated with mesenteric vein thrombosis
History and work up
Age of presentation 40 -60 years mostly males
50% personal or family history of blood clots
75% of patients symptomatic for 48 hours or more at presentation
Common presenting symptoms: Mid abdominal pain disproportionate to exam
Nausea, vomiting, diarrhea, constipation
Poor outcome predictors:
Fever (infection vs ischemia), Hemodynamic instability, Peritoneal signs
Diagnosis
Usually made non invasively
Plain abdominal films
Abnormalities 50 -75 % cases
Nonspecific findings: dilated bowel loops, ileus and mucosal edema
Can help to detect perforation
CT abdomen with contrast Diagnostic modality of choice
90% accuracy
Bowell wall thickening more than 10mm 90% accuracy for infarction
Work up
Work up
JAK2V617F screening in SVT patients without typical hematological MPN features identified MPN in 17.1% and 15.4% of screened BCS and PVT patients, respectively. It can be concluded that besides bone marrow histology, screening for JAK2V617F is an important diagnostic tool to detect MPN in these patients and should be performed in all patients with abdominal vein thrombosis as part of the standard diagnostic work-up.
Relationship between PNH and Splanchnic vein thrombosis
Flow cytometry, using monoclonal antibodies against CD55 and CD59, may identify PNH in a subclinical state when clinical and laboratory signs of hemolysis are still lacking.
Treatment
Can be managed medically if no evidence of infarction
Anticoagulation with LMWH should be started immediately after diagnosis If there is no need for invasive procedures start anticoagulation with
oral agent
Continue anticoagulation for 6 months if known reversible condition
Anticoagulation for life in pro-thrombotic states and idiopathic
Broad spectrum antibiotics if evidence of infection
Supportive care includes:
Bowel rest, NS suction, fluids/electrolyte/blood product replacement
References