Superior mesenteric and portal vein thrombosis

Case contributed by Dr Raul Javier Ibarra Fombona

Presentation

55 year old male, with acute onset of abdominal epigastric pain. No previous history of alcohol abuse, chronic hepatic disease or malignancy.

Patient Data

Age: 55 years
Gender: Male

In this case we can appreciate several abnormal findings:

  • Filling defect in the superior mesenteric vein: this is a direct sign of thrombosis. The vein has an internal hypodensity in the portal/venous phase. This thrombus has a density of 35 -40 HU. 
  • Filling defect in the portal vein: There is an extension of the thrombus to the portal vein, there is a partial filling defect in the anterior wall, witch can be seen partially extending to the right branch of the portal vein. There are no evidence of intrahepatic portal thombosis.
  • Thickened wall of jejunum and ileum: due to edema secondary to venous obstruction. There is no evident wall enhancement maybe because of amount of IV contrast injected. There are no signs of intestinal infarct because of normal arterial perfusion.
  • Dilated jejunum and ileum: with fluid filled loops an multiple air-fluid levels. This sign may indicates mechanical dysfunction due to vascular compromise.
  • Engorged veins at mesentery and free fluid between loops: this is compatible with mesenteric vascular venous congestion. The fat stranding at this level indicates certain amount  of inflammatory process. 
  • Ascites: it may indicates chronic liver disease or portal hypertension due to portal thrombosis. 
Annotated image

Superior mesenteric and portal vein thrombosis (arrows) demonstrated on multiplanar MIP images. 

Case Discussion

Acute venous mesenteric thrombosis (VMT) is not the most frequent vascular pathology of the colon and/or small intestines. Arterial compromise is far more common. Signs and symptoms are vague and nonspecific, but a soon diagnosis is key to avoid complications and even death. Bowel ischemia and infarction is common in arterial occlusion but rare in venous occlusion. It represents 5-15% of the total mesenteric ischemic events.

CT signs you should intentionally search for are: 

  • venous filling defect
  • mesenteric vein enlargement
  • collateral circulation
  • circumferential bowel wall thickening
  • pneumatosis intestinali
  • portomesenteric venous gas
  • mesenteric fat edema

Different types of intra abdominal inflammation are a common cause of VMT (pancreatitis, diverticulitis, appendicitis, etc), as well as portal hypertension, hypercoagulable states, cancer (pancreas, liver) and myeloproliferative neoplasms. Systematic search for the underlying cause is mandatory. 

PlayAdd to Share

Case information

rID: 38400
Case created: 17th Jul 2015
Last edited: 3rd Dec 2017
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.