I am a general physician practising in a public hospital in Singapore.
Superior Mesenteric Vein Thrombosis: Does It Only Happen In Cirrhosis?
A 75-year-old Chinese gentleman with significant past medical history of vascular dementia and scar epilepsy due to previous stroke, presented to our hospital with 3 days of abdominal pain. Computed tomography of abdomen and pelvis (CTAP) showed a pancreatic mass with superior mesenteric vein (SMV) thrombosis and liver metastases. As there was no safe window to perform percutaneous biopsy of the pancreatic mass, our interventional radiologist biopsied the liver lesion instead. The histology showed an adenocarcinoma compatible with pancreato-biliary origin. In view of his dementia, the decision was made for best supportive care. The SMV thrombosis was treated with a short course of enoxaparin but was stopped later due to anaemia. He passed away in a hospice 2 months later.
A 42-year-old Indonesian lady presented to our hospital with 1 week of abdominal pain. CTAP showed a perforated appendix with abscess formation and SMV thrombosis. She underwent appendicectomy and abscess drainage. She opted for Rivaroxaban for SMV thrombosis treatment despite our recommendation of using warfarin. A Doppler ultrasound of the abdomen performed 3 months later showed a patent distal SMV and portal vein. The thrombosed portion of the SMV was obscured by the stomach and small intestine. She did not develop any complication from the SMV thrombosis.
SMV thrombosis can be caused by intra-abdominal inflammation, malignancy, thrombophilia, myeloproliferative disorder and surgery. Treatment is mainly anti-coagulation and treating the underlying cause. Non-vitamin K oral anticoagulant (NOAC) is licensed for venous thromboembolism treatment and prophylaxis but the evidence of its use in SMV thrombosis treatment is limited.
In addition to cirrhosis with portal hypertension, SMV thrombosis can be caused by intra-abdominal infection or malignancy. Use of NOAC in treating SMV thrombosis due to intra-abdominal infection may be safe.