Published on October 22, 2014
1. ACD 10/16/2014 JORGE JO KAMIMOTO MD PGY 2 IM
2. 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
3. PMH: CAD, HTN, HLPD, DM II UTD on colo screening
4. 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
5. Cbc WNL, BMP shows slight AKI and slight metabolic anion gap acidosis. UA and LFTs again unremarkable
6. What is your differential diagnosis?
7. 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….
8. …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…
9. What should you do next?
10. Mesenteric vein thrombosis JORGE JO KAMIMOTO MD PGY 2 IM
11. Pathogenesis Primary vs Secondary Secondary in 75% of cases Conditions associated with mesenteric vein thrombosis
12. 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
13. 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
14. Work up
15. 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.
16. 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.
17. 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
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