MESENTERIC VENOUS THROMBOPHLEBITIS IN THE SETTING OF ACUTE DIVERTICULITIS

Objectives: Acute colonic diverticulitis presents as either uncomplicated, or complicated, with complications ranging from phlegmon, abscess, fistulae, perforation, localized peritonitis, or generalized peritonitis. Management can range from antibiotics, IR intervention, or surgical intervention. Thromboplebitis associated with diverticulitis is a rare presentation, but has been described in association with intraabdominal inflammatory states, such as appendicitis, diverticulitis, pancreatitis, and inflammatory bowel disease. We present a case of a patient with acute diverticulitis with thrombophlebitis of the inferior mesenteric and superior mesenteric veins, as well as eventual partial thrombosis of the superior mesenteric vein. This was treated in the acute setting with bowel rest, intravenous antibiotics, and anticoagulation.

The patient was a 37-year-old male with a past medical history of hypertension and asthma who presented to the emergency room with a three-day history of fever, myalgia, and intermittent abdominal pain. He continued to have normal bowel function. On evaluation he was febrile (103 F), hypotensive but fluid responsive and had a leukocytosis, and had bilateral lower abdominal tenderness. A CT abdomen/pelvis with IV contrast showed central mesenteric stranding, pelvic inflammation near sigmoid diverticuli, and central mesenteric venous intraluminal air but no associated portal venous gas. Surgery was discussed with the patient, but he was adamant that he did not want an ostomy. He was admitted, started on broad spectrum antibiotics and kept NPO.

His initial blood cultures revealed E. coli and Strep parasanguinous bacteremia. By hospital day 3 he reported less abdominal pain and was given a clear liquid diet. However, on hospital day 4 he was again febrile with a rising white blood cell count, and a repeat CT scan showed progression of the thrombophlebitis of his superior and inferior mesenteric veins, with partial superior mesenteric venous thrombosis. There was no evidence of perforation or ischemia. He was started on a heparin infusion and continued his IV antibiotics.

Following hospital day 5, he remained afebrile and his abdominal pain resolved. He was discharged on hospital day 13 on a direct acting oral anticoagulant and additional PO antibiotics. He was scheduled for follow-up in our general surgery clinic but cancelled several times and was unable to be reached by phone.

Methods:

Results:

Conclusion: