Case presentation Roni weisshof Department of Gastroenterology - PowerPoint PPT Presentation

Case presentation Roni weisshof Department of Gastroenterology Department of Gastroenterology, Rambam Health care campus

Background Background • 63 y/o man • DM type 2 Insulin treatment - not balanced DM type 2 Insulin treatment not balanced • Hypertension • Gout • Hypothyroidism • Hypothyroidism • Pituitary macroadenoma • Morbid obesity

Background Background • 2010 - Cirrhosis – Susp. NASH • Portal hypertension Portal hypertension • Hypersplenism • Varices grade 2 • Ascites • Ascites • Synthetic function normal

Current illness 5/13 5/13 • Dx of hepatic encephalopathy secondary to Cabergoline g • 6 th day of hospitalization – UGIB • Antibiotics PPI Glypressin A ibi i PPI Gl i • Gastroscopy: G s oscopy: – Esophagial varices grade 3 with red spots – Gastric verices GOV type 2 G t i i GOV t 2 – 10 band ligations

Current illness 7/13 7/13 • 27/6/13 - Liver USD – portal vein, mesenteric vein, splenic vein - patent , p p • 2/7/13 – gastroscopy 2/7/13 – Esophageal varices – grade 3 – no bleeding p g g g – Band ligation * 6 – Gastric varices Gastric varices – Hypertensive gastropathy - moderate

Current illness 6/7/13 6/7/13 • Abdominal pain – 3d gradual increment • No fever No fever • No diarrhea or vomiting • General appearance - good • General appearance - good • HR– 60/min • Abdomen – mild epigastric tenderness, no peritonitis peritonitis

Current illness 6/7/13 6/7/13 • WBC – 10.3 *10³/ μ L 13.9 *10³/ μ L • PLT - 116 *10³/ μ L PLT 116 10 / μ L • INR – 1.11 • PH – 7.42 • Bicarbonate – 19 4 mmol/L • Bicarbonate – 19.4 mmol/L • Lactate – 2.1 mmol/L 1.8 mmol/L

CT CT תנומת תנומת

CT CT תנומת תנומת

Current illness 6/7/13 6/7/13 • Abdominal CT – susp. Gastric perforation: bd i l i f i – No free air – No perforation – Ascites – Small bowel segment with thickened wall revision and 2 nd tomography: • Abdominal CT • Abdominal CT – revision and 2 tomography: – Portal vein thrombosis – Mesenteric vein thrombosis M t i i th b i – Susp. Small bowel ischemia

Current illness 6/7/13 6/7/13 • Laparoscopy: – Hemodynamic instability – Ischemic small bowel • Laparotomy – 70 cm proximal small bowel segment resection without anastomosis • 2 nd look Laparotomy 2 look Laparotomy – 50 cm resection – Primary anastomosis – Primary anastomosis

Current illness 6/7/13 6/7/13 : רואתיפוקסורקאמ : ךרואב קד יעמ עטק 48 ס " מ • דע רטוקבו 3.3 ס " מ . תיבויסנהרופא - המודאו המודאק ההכ . החיתפב - יבועב יתקצב יעמה עטק ןפוד 0.3-0.8 ס " מתיריר - הבורבההכהמודאםוירטנזמבילכוארנסמ , תררהבורב ההכ המודא . םורטנזמב לכ וארנ םישודג םד , תקצבו םידקומ םד יפטש . • רואתפוקסורקימ י : הארנ םיכתחב קמניגרומה תירירב , תיריר תתב תקצבו שדוג . םיילושםיילמיסקרפ םיילטסידו םיניקת . וארנ יבמורט םידירובםוירטנזמב .

Mesenteric vein thrombosis • First described in 1895 by Elliot • Warren and Eberhard - 1935 Warren and Eberhard 1935

N Engl J Med, Vol. 345, No. 23

Mesenteric vein thrombosis Etiology Etiology - pathogenesis pathogenesis

Mayo Clin Proc. 2013;88(3):285-294

Mesenteric vein thrombosis Etiology Etiology - pathogenesis pathogenesis • Up to 50% of patient have a personal or family history of DVT or PE y • Up to 75% of patients have an inherited thrombotic disorder thrombotic disorder • JAK2V617F occurs in 41% of patients with idiopathic chronic portal, splenic and mesenteric venous thrombosis mesenteric venous thrombosis Am J Gastroenterol. 2001;96(1):146 Aliment Pharmacol Ther 31, 1330–1336

Mesenteric vein thrombosis Etiology Etiology - pathogenesis pathogenesis • Isolated MVT - thrombosis of the smaller branches of the superior mesenteric vein p • Combined MVT - thrombosis of the superior mesenteric vein associated with thrombosis of mesenteric vein associated with thrombosis of the splenic or portal vein AJG – Vol. 98, No. 6, 2003

Mesenteric vein thrombosis Etiology Etiology - pathogenesis pathogenesis • Isolated MVT – More inherited hypercoagulable disorders yp g – More history of previous thrombosis – More bowel necrosis – More surgeries AJG – Vol. 98, No. 6, 2003

Gut 2005; 54:691-7

Mesenteric vein thrombosis Cirrhosis Cirrhosis • A thrombophilic genotype was detected in 69.5% of the patients with PVT p • 43.5% MTHFR • FVL FVL • Prothrombin o o b Hepatology. 2000 Feb;31(2):345-8.

Mesenteric vein thrombosis Cirrhosis Cirrhosis • Sclerotherapy – rare complication – Sclerosant flow into mesenteric vessels – Disturbing portal hemodynamics – Synchronous use with vasopressin Synchronous use with vasopressin • retrograde propagation of thrombus into the portal venous system ? venous system ? Am J Gastroenterol. 1989 Mar;84(3):306-10 Am J Gastroenterol. 1987 Dec;82(12):1297-300

Endoscopic band ligation mesenteric vein thrombosis mesenteric vein thrombosis • 64 y/o woman • Idiopathic portal hypertension Idiopathic portal hypertension • Abdominal pain, vomiting, fever – 4 months after EBL f EBL • Isolated MVT so ed V • Extensive venous collateral circulation • Conservative treatment J Gastroenterol 1995; 30:254-257

Endoscopic band ligation Hemodynamics Hemodynamics • Alterations in portal hemodynamics • Migration of thrombi from the submucosa Migration of thrombi from the submucosa – Formation of thrombi in the tortuous varices remaining in the submucosa remaining in the submucosa Am J Gastroenterol. 1993 Feb;88(2):272-4

Endoscopic band ligation Hemodynamics Hemodynamics • Elevation (not significant) in the portal pressure p • Increases both the incidence and the severity of Portal hypertensive gastropathy and Fundal of Portal hypertensive gastropathy and Fundal varices formation • Spinal cord venous infarction Neurology 2003; 60: 879–880 Journal of Hepatology 1996; 24: 74-80 Dig Dis Sci. 2006 Jan;51(1):27-30

Back to the patient Back to the patient • 24 days after first admission USD: d f fi d i i – IVC and hepatic arteries + veins – open – Splenic vein open – Thrombus in left portal branch p • 1 month later • 1 month later – susp. Pulmonary Embolism susp Pulmonary Embolism in chest CT • (new ? Old ?) ( ? Old ?) • No DVT

Back to the patient 30 10 13 30.10.13 • Prophylactic anticoagulation (60mg Enoxaparin) p ) • Some rectal bleeding (hemorrhoids ?) • No UGI bleeding N UGI bl di

Back to the patient p • Cirrhosis pt. very recent normal USD • New onset after EVL New onset after EVL • SMV + PV • PE ? • Thrombophilia ? • Ligation ? • Cirrhosis ? • Cirrhosis ?