Presentation
Generalized abdominal pain, distension and guarding for 6 hours.
Patient Data
Multiple loops of mid and distal ilium are markedly edematous and show reduced contrast enhancement within their walls. The adjacent mesentery is also markedly edematous. Free fluid of moderate extent in pelvis and also surrounding liver and spleen. No free gas detected to suggest perforation.
The superior mesenteric artery is intact, but the superior mesenteric vein is occluded by thrombus, the leading edge of which extends into the distal end of the superior mesenteric vein, just proximal to its junction with the splenic vein. Large bowel and appendix are normal. Liver diffusely fatty.
A large thrombus (blue arrow) is seen filing the right sided branches of the superior mesenteric vein, with a tongue of thrombus extending up almost to the pancreas. The bowel drained by these occluded branches is thick-walled and poorly enhancing (blue dotted line).
Branches draining the more proximal small bowel remain patent (green arrow) and jejunal loops appear to have normal wall thickness (greed dotted line) although enhancement cannot adequately be assessed due to positive luminal contrast.
Some loops of distal ileum have hyperdense walls (yellow dotted line), which would represent enhancement or, more likely in this setting, submucosal red cell extravasation. This is why a non-contrast initial scan is useful.
The patient was taken to the operating theater for an emergency laparotomy and had a segment of small bowel excised.
MACROSCOPIC DESCRIPTION: Specimen comprised of long segment of small intestine measuring approximately 400mm long x20mm in diameter with attached mesentery up to 30mm wide. There is dark brown discolouration of the full thickness of the small intestine extending to 70mm from one margin and 200mm from the opposite margin.
MICROSCOPIC DESCRIPTION: The sections of small bowel show full thickness hemorrhagic infarction comprising necrosis of the mucosa and muscularis propria with associated hemorrhage. Vessels are intensely congested and there is intramural edema. Sections taken from the mesentery show organizing thrombus predominantly within venous channels. Margins are viable. No evidence of tumor is seen.
FINAL DIAGNOSIS: Hemorrhagic infarction secondary to mesenteric venous thrombosis.
Case Discussion
Although superior mesenteric vein thrombosis is a relatively uncommon cause of intestinal ischemia, the diagnosis can usually be made on the grounds of a contrast enhanced CT and can significantly influence management.
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