Mesenteric ischemia - venous

Case contributed by Dr Brian Gilcrease-Garcia

Presentation

History of distal pancreatectomy and splenectomy for neuroendocrine carcinoma. Now presenting with mid-abdominal pain

Patient Data

Age: 60 years
CT
  • changes of distal pancreatectomy and splenectomy, with absence of the splenic and portal veins
  • extensive collateral veins starting at the mesenteric root, following the cystic duct and gallbladder, consistent with cavernous transformation. Also extensive gastroepiploic and proximal gastric collaterals
  • thickening of a segment of small bowel at mid/right abdomen, more specifically with mucosal hyperenhancement and submucosal edema
  • mesenteric thickening/stranding associated with above segment of small bowel, which can be traced back to the mesenteric root
  • mesenteric and retroperitoneal lymphadenopathy
  • moderate free intraperitoneal fluid, mostly along paracolic gutters

Operative Findings

  • significant ascites, without purulence or feculence
  • significant mesenteric venous congestion throughout small bowel mesentery, which was inflamed and thickened up to 3 cm
  • 10 cm segment of mid jejunum with mild ischemia, but no concerns for significant ischemia or necrosis - no resection was performed

Case Discussion

This case demonstrates both classic findings of superior mesenteric vein (SMV) and chronic portal vein thrombosis:

  • non-opacification of SMV, small bowel thickening, together with dramatic mesenteric stranding ("misty mesentery") all the way up to the superior mesenteric root
  • non-opacification of portal vein, with extensive venous collateral vessels at the level of the portosplenic confluence, hepatic hilum, and along the extrahepatic biliary structures (cavernous transformation)

The development of collateral flow is evidence that these findings are chronic; however, the patient's acute symptoms prompted concern for component of acute ischemia. 

The imaging findings of mesenteric venous insufficiency were confirmed by the operative findings. In this case, it was decided against bowel resection due to high risk of failure and post-operative leak in the context of venous insufficiency.

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Case information

rID: 64957
Published: 16th Dec 2018
Last edited: 4th Mar 2019
Inclusion in quiz mode: Included
Institution: Mallinckrodt Institute of Radiology at Washington University

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