HYPERCOAGUABLE FACTORS ATTRIBUTING TO SUPERIOR MESENTERIC VEIN THROMBOSIS AND ACUTE MESENTERIC ISCHEMIA - A CASE REPORT

Objectives: Acute mesenteric ischemia from venous thrombosis is rare and can be difficult to diagnose due to vague symptoms often endorsed by patients. It can be fatal if not discovered in time, as it can lead to bowel necrosis, sepsis, and ultimately death. We present a case of a twenty-three year old female with hepatic steatosis, obesity, and five-year history of birth control use who developed acute mesenteric ischemia secondary to superior mesenteric venous thrombosis, requiring small bowel resection of 238 cm out of 480 cm (49.5%) after delay in diagnosis.

Patient is a twenty-three year old female with past medical history significant for headaches, hepatic steatosis, BMI 42, and birth control (estradiol-norgestimate) use for approximately 5 years, as well as family history significant for blood clots in her maternal grandmother. She presented multiple times to another hospital with vague abdominal symptoms prior to diagnosis of superior mesenteric vein and portal vein thrombosis with concern for bowel ischemia. Her symptoms included abdominal pain, nausea, vomiting, and bloody bowel movements. She was started on a heparin infusion, but by the time of her transfer, the patient was tachycardic, hypotensive, tachypneic, with elevated lactate, and focal peritonitis. She was taken to the operating room for diagnostic laparoscopy which was converted to exploratory laparotomy shortly after entering the abdomen, as frank bowel necrosis was encountered immediately. Almost half of the patient’s bowel was resected over two operations. Her hospital course was further complicated by acute hypoxic respiratory failure, pneumonia, acute renal failure, and gastrointestinal bleed.

Mesenteric ischemia can be due to acute or chronic processes. Acute mesenteric ischemia (AMI) can be further attributed to arterial or venous pathologies. AMI secondary to superior mesenteric venous thrombosis specifically can be challenging to diagnose, as symptoms described by patients are often non-specific. Time is of the essence as swift diagnosis is essential to saving as much small bowel as possible for maximal functional outcomes and for preventing hospital course complications resulting from morbidity of disease. Hypercoagulable workup was negative; however, this patient may have been at high risk for thrombus due to other factors including her long-term birth control use, morbid obesity, and hepatic steatosis.

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