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

• 6th day of hospitalization – UGIB

A ibi i PPI Gl i

• Antibiotics PPI Glypressin
• Gastroscopy:

G s oscopy:

– Esophagial varices grade 3 with red spots G t i i GOV t 2 – Gastric verices GOV type 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

• 2/7/13 – gastroscopy

– 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/μL 13.9 *10³/μL
• PLT - 116 *10³/μL

PLT 116 10 /μL

• 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

תנומת CTתנומת CT

תנומת CTתנומת CT

Current illness 6/7/13

bd i l i f i

6/7/13

• Abdominal CT – susp. Gastric perforation:

– No free air – No perforation – Ascites – Small bowel segment with thickened wall

• Abdominal CT

revision and 2nd tomography:

• Abdominal CT – revision and 2

tomography:

– Portal vein thrombosis M t i i th b i – Mesenteric vein thrombosis – 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

• 2nd look Laparotomy

2 look Laparotomy

– 50 cm resection – Primary anastomosis – Primary anastomosis

Current illness 6/7/13 6/7/13

• :רואתיפוקסורקאמ: ךרואב קד יעמ עטק48 ס"מ

דע רטוקבו3.3ס"מ .תיבויסנהרופא- המודאו המודאק ההכ . החיתפב- יבועב יתקצב יעמה עטק ןפוד0.3-0.8 ס"מתיריר-הבורבההכהמודאםוירטנזמבילכוארנסמ,תררהבורב ההכ המודא.םורטנזמב לכ וארנ םישודג םד ,תקצבו םידקומ םד יפטש.

• רואתפוקסורקימי:הארנ םיכתחבקמניגרומה

תירירב,תיריר תתב תקצבו שדוג.םיילושםיילמיסקרפ םיילטסידו םיניקת . וארניבמורט 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 pathogenesis Etiology - pathogenesis

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

Mesenteric vein thrombosis Etiology pathogenesis Etiology - 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 pathogenesis Etiology - 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 pathogenesis Etiology - 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
• 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

f EBL after 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
• f Portal hypertensive gastropathy and Fundal
• f 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

d f fi d i i

• 24 days after first admission USD:

– IVC and hepatic arteries + veins – open – Splenic vein open – Thrombus in left portal branch p

• 1 month later

susp Pulmonary Embolism

• 1 month later – susp. Pulmonary Embolism

in chest CT ( ? Old ?)

• (new ? Old ?)
• No DVT

Back to the patient 30 10 13 30.10.13

• Prophylactic anticoagulation (60mg

Enoxaparin) p )

• Some rectal bleeding (hemorrhoids ?)

N UGI bl di

• No UGI bleeding

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 ?