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Fig. 1. Image from the admission abdominal CT. |
Fig. 2. Image from the admission abdominal CT. |
Case Reference No. CC-397-02 The patient is a 42-year-old previously healthy white male who presents to his internist with flu-like symptoms. Nausea, vomiting, diarrhea remit but are replaced by abdominal distension and severe pain whenever he eats anything. He is on no medications. He has no significant previous medical history. His family history is notable for thromboembolic disease in several relatives. Physical exam is significant for abdominal distension, tympany, diffuse tenderness without peritoneal signs, quiet infrequent bowel sounds, and temp of 99 degrees. He is guaiac negative. Labs significant for mild leukocytosis and pre-renal azotemia. Figures 1-3 are images from the admission abdominal CT, showing thrombosis of the right portal and superior mesenteric veins as well as soft tissue density at the mesenteric root. Fig. 4 is venous-phase image of SMA arteriogram. |
Fig. 3. Image from the admission abdominal CT.
Fig. 4. Venous-phase image of SMA arteriogram. |
Fig. 5. Venous-phase image of splenic arteriogram. |
Fig. 6. Transhepatic porto-mesenteric venogram. |
Figure 5 is venous-phase image of splenic arteriogram. Figure 6 is transhepatic porto-mesenteric venogram after 90 hours of Urokinase infusion both via SMA and transhepatic catheters, repeated balloon angioplasty of SMV branches and main trunk, and systemic heparinization. The main SMV was very resistant to dilatation and demonstrated significant immediate elastic recoil. Procedure was terminated due to staph sepsis. Prophylactic antibiotics were not given during infusion. Questions 1) What is the etiology of the SMV thrombosis? 2) Would you have treated him similarly? 3) Would you have used or considered mechanical thrombectomy devices? Stents? At what point? 4) Do you routinely give prophylactic antibiotics during thrombolysis? 5) Should he be anticoagulated? How long? Related cases: |
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