Gastrointestinal bleeding due to obstruction of the superior mesenteric vein.

ABSTRACT: Gastrointestinal bleeding is a common clinical symptom. Finding the underlying cause is the first step for treatment. In a few patients, this can be difficult. The present work reports on the unusual case of a 53-year-old man who presented gastrointestinal bleeding. No bleeding site was found by gastrocolonoscopy or interventional examination, but after multidisciplinary consultation, we discovered that the cause of gastrointestinal bleeding was the obstruction of the upper mesenteric vein.

Mesenteric Vein Thrombosis following Sleeve Gastrectomy: A Case Report and Review of the Literature.

INTRODUCTION: Acute mesenteric ischemia (AMI) is a rare but lethal disease. Mesenteric vein thrombosis (VAMI) is a subtype of AMI. Morbid obesity is usually accompanied by hypertension, hyperlipidemia, or diabetes mellitus, which are risk factors associated with AMI. CASE PRESENTATION: We present a 28-year-old man with VAMI post-laparoscopic sleeve gastrectomy. He was first misdiagnosed with intestinal obstruction. Superior VAMI was confirmed after computed tomography angiography. Laparotomy, resection of the necrotic small bowel, and ostomy were performed immediately. CONCLUSION: Patients with morbid obesity accompanied by hypertension, hyperlipidemia, or diabetes mellitus have a high risk of AMI. Abdominal pain with sudden onset should be considered AMI. Anticoagulation therapy post-sleeve gastrectomy might help reduce the incidence of AMI.

Superior mesenteric vein thrombosis due to COVID-19 vaccination: a case report.

BACKGROUND: The worldwide vaccination response to COVID-19 has been associated with rare thrombotic complications, including the case of postvaccination splanchnic venous thrombosis we report here. CASE PRESENTATION: An 80-year-old Japanese male with abdominal pain presented to our hospital six days after receiving a dose of the COVID-19 messenger ribonucleic acid vaccine. Abdominal computed tomography showed localized edema of the small intestine, increased density of the surrounding adipose tissue, and a thrombus in the superior mesenteric vein. Conservative inpatient treatment with unfractionated heparin relieved the thrombosis, and the patient is currently receiving oral apixaban as an outpatient. CONCLUSION: Reported cases of thrombosis after COVID-19 vaccination typically have been associated with viral vector vaccines, with few reports of thrombosis induced by mRNA vaccines. The potential for venous thrombosis should be explored when patients present with abdominal pain soon after COVID-19 vaccination.

Idiopathic mesenteric phlebosclerotic colitis associated with Chinese herbal medicine.

Idiopathic mesenteric phlebosclerotic colitis(IMP) is a rare disease. At present, the etiology and pathogenesis are not clear, but the main patients are Asian people, and most of them have a history of taking Chinese herbal medicines. The disease has characteristic endoscopic and imaging manifestations. This paper shares a case of IMP, The patient came to our hospital for one year because of intermittent abdominal pain and diarrhea. It conforms to the typical manifestations of IMP. For patients who take Chinese herbal medicine for a long time, if they have clinical manifestations of gastrointestinal tract, it is necessary to consider the possibility of the disease to avoid serious consequences due to missed diagnosis.

CT findings in idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) and comparison to other colitides.

PURPOSE: The purpose of this study is to determine computed tomography (CT) findings that aid in differentiating idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) from other colitides. METHODS: Retrospective review of histiologic proven cases of IMHMV (n = 12) with contrast enhanced CT (n = 11) and/or computed tomography angiography (CTA) (n = 9) exams. Control groups comprised of CT of infectious colitis (n = 13), CT of inflammatory bowel disease (IBD) (n = 12), and CTA of other colitides (n = 13). CT exams reviewed by 2 blinded gastrointestinal radiologists for maximum bowel wall thickness, enhancement pattern, decreased bowel wall enhancement, submucosal attenuation value, presence and location of IMV occlusion, peripheral mesenteric venous occlusion, dilated pericolonic veins, subjective IMA dilation, maximum IMA diameter, maximum peripheral IMA branch diameter, ascites, and mesenteric edema. Presence of early filling veins was an additional finding evaluated on CTA exams. RESULTS: Statistically significant CT findings of IMHMV compared to control groups included greater maximum bowel wall thickness, decreased bowel enhancement, IMV occlusion, and peripheral mesenteric venous occlusion (p < 0.05). Dilated pericolonic veins were seen more frequently in IMHMV compared to the infectious colitis group (64% versus 15%, p = 0.02). Additional statistically significant finding on CTA included early filling veins in IMHMV compared to the CTA control group (100% versus 46%, p = 0.008). CONCLUSION: IMHMV is a rare chronic non-thrombotic ischemia predominantly involving the rectosigmoid colon. CT features that may aid in differentiating IMHMV from other causes of left-sided colitis include marked bowel wall thickening with decreased enhancement, IMV and peripheral mesenteric venous occlusion or tapering, and early filling of dilated veins on CTA.

Three-dimensional Computed Tomography Evaluation of the Vasculature of Right-side Colon Cancer.

BACKGROUND/AIM: From an oncological perspective, central ligation of the feeding vessel is an important approach to consider when performing colon cancer surgery. This study aimed to use three-dimensional computed tomography (3D-CT) to clarify the vascular anatomy for performing central vascular ligation to improve the accuracy of minimally invasive surgery (MIS) performed to treat advanced right-side colon cancer. PATIENTS AND METHODS: This descriptive study was conducted at one institution and targeted 92 patients with right-side colon cancer whose vascular anatomy was evaluated with 3D-CT before surgery between January 2014 and December 2020 at Tokyo Medical University Hospital. RESULTS: In 49 patients (53.3%), the ileocolic artery was ventral to the superior mesenteric vein (SMV), whereas in 43 patients (46.7%), it was dorsal to the SMV. The right colic artery was present in 31 patients (33.7%). The middle colic artery was present in all patients (100%). A common duct type was present in 80 patients (87.0%). Branching directly from the superior mesenteric artery without a common duct was observed in 12 patients (13.0%). Twenty-one patients (22.9%) had an accessory superior mesenteric artery. CONCLUSION: The vascular structure of the right-side colon is highly complex. Conducting 3D-CT evaluations of the vessel anatomy is very useful for surgeons who conduct MIS, and is considered to enable central ligation to be performed safely and improve the quality of surgery, which will benefit patients.

Investigation of the variation of vessels around the pancreatic head based on the first jejunal vein anatomy at pancreaticoduodenectomy.

PURPOSE: Pancreaticoduodenectomy (PD) for pancreatic cancer carries a high risk of massive intraoperative blood loss. The artery first approach (AFA) prevents blood loss during PD, but the optimal approach is unclear. The first jejunal vein (FJV) often comprises multiple veins and broadly supports venous drainage of the proximal jejunum. Its ligation carries a risk of proximal jejunum congestion. Here we investigated the anatomical characteristics of PD-associated vessels and AFA approach selection based on FJV anatomy. METHODS: This study included 148 Japanese living donors for liver transplantation. We reviewed their computed tomography images and assessed the anatomical pattern of PD-associated vessels in terms of FJV anatomy. RESULTS: The FJV traveled posterior to the superior mesenteric artery in 128 patients (86.5%, dorsal group) and anterior in 20 (13.5%, ventral group). The predominant draining vein of the inferior pancreaticoduodenal vein was the superior mesenteric vein in the ventral group (87.5%) and the FJV in the dorsal group (97.9%). Compared with the dorsal group, the ventral group had a significantly greater percentage with the superior mesenteric vein ventral to the superior mesenteric artery (30.0% versus 10.9%) and a significantly larger posterior superior pancreaticoduodenal vein diameter (3.2 ± 0.9 versus 2.7 ± 0.6 mm, p = 0.0029). These results were validated in patients with pancreatic head cancer. CONCLUSIONS: The anatomical characteristics of PD-associated vessels differed significantly between groups defined by FJV anatomy. Understanding the venous anatomy, especially the FJV, could support selection of the best approach in AFA for PD.

Acute mesenteric ischemia secondary to superior mesenteric vein thrombosis in a patient with liver cirrhosis: A case report.

RATIONALE: Acute mesenteric ischemia due to superior mesenteric vein (SMV) thrombosis is a rare yet potentially life-threatening emergency. Our case report explores this condition in the context of a patient with liver cirrhosis due to Wilson disease. We specifically highlight the complex derangement of the coagulative balance in liver cirrhosis. PATIENT CONCERNS: A 34-year-old female with Wilson disease-related cirrhosis presented with intractable abdominal pain, nausea, and vomiting that showed no response to antispasmodic medication. DIAGNOSES: A contrast-enhanced abdominal computed tomography scan and Doppler ultrasound confirmed an intraluminal filling defect in the SMV, leading to the diagnosis of SMV thrombosis. INTERVENTIONS: Prompt anticoagulation, intravenous fluids, and an antibiotic were initiated. Surgical consultation recommended conservative therapy with close monitoring. OUTCOMES: Over the following 2 days, the patient's condition improved considerably, with almost complete resolution of her symptoms. Genetic testing identified a 4G/4G homozygous genotype of the plasminogen activator inhibitor 1 gene, associated with a higher risk of thrombosis in the vessels of internal organs. After 2 months of sustained anticoagulant therapy, a follow-up contrast-enhanced computed tomography scan revealed near-complete recanalization of the SMV, and the patient remained symptom-free. LESSONS: This case underscores the importance of early detection and treatment of acute mesenteric ischemia in patients with liver cirrhosis, as well as the potential role of genetic factors in thrombosis.

Variations of the double superior mesenteric vein are not rare: An observational study using computed tomography, three-dimensional image reconstruction, and surgery.

INTRODUCTION: Few studies have evaluated variations of the main trunk of the superior mesenteric vessels. Particularly, the double superior mesenteric vein (DSMV) has not been described in detail. This study aimed to establish the definition, anatomical characteristics, and underlying clinical significance of the DSMV. MATERIALS AND METHODS: A total of 115 patients with colorectal cancer were included in this retrospective study between March 2020 and March 2022. The anatomical characteristics were analyzed using computed tomography, three-dimensional image reconstructions, and surgical videos. RESULTS: Among the patients enrolled, 22 (19.1%) had DSMVs. The median diameters of the right and left superior mesenteric veins were similar. The superior mesenteric artery was sandwiched between the right and the left superior mesenteric veins. The left superior mesenteric vein mainly crossed the ventral side of the superior mesenteric artery (63.6%). In 1 case, the right superior mesenteric vein was mistakenly resected intraoperatively. The DSMV was classified into types I and II based on whether the right and left trunks formed a common trunk; it was further classified into subtypes a and b based on the colonic vein confluence. The proportions of type I-a, I-b, II-a, and II-b were 4.5%, 27.3%, 9.1%, and 59.1%, respectively. The middle colic veins drained into the left superior mesenteric vein in 19 cases (86.4%). CONCLUSIONS: The DSMV is more common than previously thought. For the first time, the definition and four types of the DSMV were proposed. The presence of a DSMV should be considered during right hemicolectomies.

Pediatric hypereosinophilic syndrome associated with liver damage, portal vein, splenic vein and superior mesenteric vein thromboses: a case report.

BACKGROUND: The hypereosinophilic syndrome (HES) is a group of rare blood disorders characterized by persistent eosinophilia and damage to multiple organs. HES can be either primary, secondary or idiopathic. Secondary HES are commonly caused by parasitic infections, allergic reactions or cancer. We described a pediatric case of HES associated with liver damage and multiple thrombi. A 12-year-old boy with eosinophilia was complicated with severe thrombocytopenia, liver damage, portal vein, splenic vein, and superior mesenteric vein thromboses. The thrombi recanalized after treatment with methylprednisolone succinate and low molecular weight heparin. No side effects appeared after 1-month. CONCLUSIONS: Corticosteroids should be used at an early stage of HES to prevent further damage to vital organs. Anticoagulants should be recommended only in cases with thrombosis which should be actively screened as a part of evaluation of end organ damage.

Idiopathic myointimal hyperplasia of the mesenteric veins: A systematic review and individual patient data regression analysis.

BACKGROUND AND AIM: Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is an uncommon cause of colonic ischemia for which surgical treatment is typically curative. We describe clinical, radiologic, and endoscopic findings in IMHMV patients to provide clinicians with a framework for pre-surgical identification of this rare disease. METHODS: We performed a systematic review of seven databases for IMHMV cases and identified additional cases from Yale New Haven Hospital records. To identify features specifically associated with colonic ischemia due to IMHMV, we performed multivariate logistic regression analysis incorporating data from a large cohort of patients with biopsy-proven ischemic colitis. RESULTS: A total of 124 patients with IMHMV were identified (80% male, mean age 53 years, 56% Caucasian). Presenting symptoms were most commonly abdominal pain (86%) and diarrhea (68%). The most affected areas were the sigmoid colon (91%) and rectum (61%). Complications associated with diagnostic delay occurred in 29% of patients. Radiologic vascular abnormalities including non-opacification of the inferior mesenteric vein were observed in 35% of patients. Of the patients, 97% underwent curative surgical resection. Compared with non-IMHMV colonic ischemia, IMHMV was significantly associated with younger age, male sex, absence of rectal bleeding on presentation, rectal involvement, and mucosal ulcerations on endoscopy. CONCLUSION: IMHMV is a rare, underreported cause of colonic ischemia that predominantly involves the rectosigmoid. Our findings suggest younger age, rectal involvement, and absence of rectal bleeding as clinical features to help identify select patients presenting with colonic ischemia as having higher likelihood of IMHMV and therefore consideration of upfront surgical management.

An Ingested Bone Perforating Through the Stomach into the Superior Mesenteric Vein.

Here, we describe a case of an 86-year-old man presenting with several days of abdominal pain. Computed tomography (CT) demonstrated a radiopaque object penetrating through the stomach into the superior mesenteric vein. He was taken for exploratory laparotomy where a sharp object was noted to be extending through the posterior wall of the stomach. To control the body, an anterior gastrotomy was performed. There was no hemorrhage noted from the retroperitoneum. On gross inspection, the foreign body appeared to be consistent with a large fragment of bone. On discussion with the patient, he noted consuming a large pork chop prior to the onset of his abdominal pain. He recovered well without significant complication and was able to return home. Subsequent follow up confirmed his continued convalescence.

Laparoscopic pancreaticoduodenectomy with portal or superior mesenteric vein resection and reconstruction for pancreatic cancer: A single-center experience.

BACKGROUND: Open pancreaticoduodenectomy (OPD) with portal or superior mesenteric vein resection and reconstruction has been applied in pancreatic cancer patients with tumor infiltration or adherence. However, it is controversial whether laparoscopic pancreaticoduodenectomy (LPD) with major vascular resection and reconstruction is feasible. This study aimed to evaluate the safety and feasibility of LPD with major vascular resection compared with OPD with major vascular resection. METHODS: We reviewed data for all pancreatic cancer patients undergoing LPD or OPD with vascular resection at Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, between February 2018 and May 2022. We compared the preoperative, intraoperative, and postoperative clinicopathological data of the two groups to conduct a comprehensive evaluation of LPD with major vascular resection. RESULTS: A total of 63 patients underwent pancreaticoduodenectomy (PD) with portal or superior mesenteric vein resection and reconstruction, including 25 LPDs and 38 OPDs. The LPD group had less intraoperative blood loss (200 vs. 400 mL, P < 0.001), lower proportion of intraoperative blood transfusion (16.0% vs. 39.5%, P = 0.047), longer operation time (390 vs. 334 min, P = 0.004) and shorter postoperative hospital stay (11 vs. 14 days, P = 0.005). There was no perioperative death in all patients. There was no significant difference in the incidence of total postoperative complications, grade B/C postoperative pancreatic fistula, delayed gastric emptying and abdominal infection between the two groups. No postpancreatectomy hemorrhage nor bile leakage occurred during perioperative period. There was no significant difference in R0 resection rate and number of lymph nodes harvested between the two groups. Patency of reconstructed vessels in the two groups were 96.0% and 92.1%, respectively (P = 0.927). CONCLUSIONS: LPD with portal or superior mesenteric vein resection and reconstruction was safe, feasible and oncologically acceptable for selected patients with pancreatic cancer, and it can achieve similar or even better perioperative results compared to open approach.