Mesenteric venous thrombosis as a complication of appendicitis in an adolescent

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Abstract

Rationale:

Mesenteric venous thrombosis is an uncommon but potentially fatal condition that can cause bowel ischemia. It results from a systemic hypercoagulable state or abdominal infection draining into the portal venous system. Several cases regarding portomesenteric venous thrombosis as a complication of appendicitis were reported in adults, but there are far fewer reports in pediatric patients. The mortality rate of the condition is high if untreated, especially in children, reaching up to 50%.

Patient concerns:

A healthy 15-year-old male with no significant past medical history presented with right lower quadrant pain, lethargy, and fever. The computed tomography scan showed a focal thrombosis at the superior mesenteric vein branch and an inflamed appendix.

Diagnoses:

Mesenteric venous thrombosis complicating acute appendicitis.

Interventions:

Intravenous antibiotics along with anticoagulants and laparoscopic appendectomy

Outcomes:

After 1 month, a follow-up ultrasonography revealed full resolution of the thrombosis.

Lessons:

Appendicitis is one of the most frequently encountered causes of pediatric surgical emergencies; therefore, physicians should be conscious of mesenteric venous thrombosis as a possible complication of acute appendicitis, irrespective of whether patients have thrombophilic conditions or not.

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Most cited references 46

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New oral anticoagulants: their advantages and disadvantages compared with vitamin K antagonists in the prevention and treatment of patients with thromboembolic events

Ymer Mekaj, Agon Y Mekaj, Shkelzen B Duci … (2015)

Despite the discovery and application of many parenteral (unfractionated and low-molecular-weight heparins) and oral anticoagulant vitamin K antagonist (VKA) drugs, the prevention and treatment of venous and arterial thrombotic phenomena remain major medical challenges. Furthermore, VKAs are the only oral anticoagulants used during the past 60 years. The main objective of this study is to present recent data on non-vitamin K antagonist oral anticoagulants (NOACs) and to analyze their advantages and disadvantages compared with those of VKAs based on a large number of recent studies. NOACs are novel direct-acting medications that are selective for one specific coagulation factor, either thrombin (IIa) or activated factor X (Xa). Several NOACs, such as dabigatran (a direct inhibitor of FIIa) and rivaroxaban, apixaban and edoxaban (direct inhibitors of factor Xa), have been used for at least 5 years but possibly 10 years. Unlike traditional VKAs, which prevent the coagulation process by suppressing the synthesis of vitamin K-dependent factors, NOACs directly inhibit key proteases (factors IIa and Xa). The important indications of these drugs are the prevention and treatment of deep vein thrombosis and pulmonary embolisms, and the prevention of atherothrombotic events in the heart and brain of patients with acute coronary syndrome and atrial fibrillation. They are not fixed, and dose-various strengths are available. Most studies have reported that more advantages than disadvantages for NOACs when compared with VKAs, with the most important advantages of NOACs including safety issues (ie, a lower incidence of major bleeding), convenience of use, minor drug and food interactions, a wide therapeutic window, and no need for laboratory monitoring. Nonetheless, there are some conditions for which VKAs remain the drug of choice. Based on the available data, we can conclude that NOACs have greater advantages and fewer disadvantages compared with VKAs. New studies are required to further assess the efficacy of NOACs.

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Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era.

D Dooley, R Plemmons, Robert N Longfield (1995)

Pylephlebitis usually occurs secondary to infection in the region drained by the portal venous system. We describe a case of pylephlebitis at our institution and examine 18 other cases culled from the literature since 1979, reviewing diagnostic and management issues. A precipitating focus of infection (most commonly diverticulitis) was identified in 13 (68%) of the cases. Bacteremia (often polymicrobial) was present in 88% of the patients. The most common blood isolate was Bacteroides fragilis. Overall mortality was 32%, but most of the patients who died had severe sepsis prior to the initiation of antibiotic therapy. In no case was improvement in a patient's clinical status clearly attributable to the use of heparin, but some beneficial effect of anticoagulation could not be ruled out. This report is the first to examine the published experience with pylephlebitis during the era of antibiotics and modern imaging and is also the first to review critically the role of anticoagulation in the management of this disease.

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Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy.

D Valla, B Condat, M H Denninger … (2000)

Characteristics and outcomes of recent portal or mesenteric venous thrombosis are ill-known. We intended to compare these features with those of patients with portal cavernoma, and also to assess the incidence of recanalization of recent thrombosis on anticoagulation therapy. All patients seen between 1983 and 1999 were enrolled into this retrospective study if recent portal or mesenteric venous thrombosis or portal cavernoma had been documented, and if cancer of the liver, pancreas, or bile duct, intrahepatic block including cirrhosis, and obstruction of the hepatic veins had been ruled out. The proportion of recent thrombosis was 7% in patients seen before 1990 and 56% after 1994 (P <.05). Patients with recent thrombosis (n = 33) or cavernoma (n = 108) did not differ with regard to age, sex ratio, or prevalence of prothrombotic states and of previous thrombotic events. In patients with recent thrombosis, septic pylephlebitis was more common and the incidence of gastrointestinal bleeding was lower (2.4 vs. 12.7/100 patient-years). Recanalization occurred in 25 of 27 patients given anticoagulation and 0 of 2 patients not given anticoagulation. The probability of recanalization was related to the extent of thrombosis (P =.003). In conclusion, mesenteric or portal venous thrombosis is increasingly recognized at an early stage. The features differentiating recent thrombosis and cavernoma are related to silent onset precluding early recognition and therapy in the latter. Frequent association with prothrombotic states and frequent recanalization on anticoagulation support the recommendation of early anticoagulation therapy in all patients with recent portal vein thrombosis.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date Collection: November 2019

Publication date (Electronic): 27 November 2019

Volume: 98

Issue: 48

Electronic Location Identifier: e18002

Affiliations

[a ]Division of Pediatric Emergency Medicine, Department of Pediatrics, Severance Children's Hospital

[b ]Department of Radiology, Severance Hospital, Research Institute of Radiological Science

[c ]Division of Pediatric Cardiology, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Department of Pediatrics

[d ]Department of Pediatric Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.

Author notes

[∗ ]Correspondence: Moon Kyu Kim, Division of Pediatric Emergency Medicine, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea (e-mail: MKIM@ 123456yuhs.ac ).

Article

Publisher ID: MD-D-19-04821 Accession ID: 18002

DOI: 10.1097/MD.0000000000018002

PMC ID: 6890307

PubMed ID: 31770213

SO-VID: 4dfdae0a-62ab-47d2-927e-27f0b16957ac

License:

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

History

Date received : 22 June 2019

Date revision received : 04 October 2019

Date accepted : 17 October 2019

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Keywords: adolescent,appendicitis,complication,mesenteric venous thrombosis,superior mesenteric vein thrombosis

Data availability:

Keywords: adolescent, appendicitis, complication, mesenteric venous thrombosis, superior mesenteric vein thrombosis

Mesenteric venous thrombosis as a complication of appendicitis in an adolescent : A case report and literature review

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Abstract

Rationale:

Patient concerns:

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Interventions:

Outcomes:

Lessons:

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Network Medicine

Most cited references 46

New oral anticoagulants: their advantages and disadvantages compared with vitamin K antagonists in the prevention and treatment of patients with thromboembolic events

Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era.

Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy.

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