acd 10/16: a case of abdominal pain

ACD 10/16/2014JORGE JO KAMIMOTO MD PGY 2 IM

Simulated case presentation

Elderly man that presents to ED for: Intermittent abdominal pain on and off for 1 week associated with

constipation

Usually notices it after eating or drinking

Subjective fever for 24 hours

PMH: CAD, HTN, HLPD, DM II

UTD on colo screening

Vitals:

Bp 125/75 mmHg, Hr 130, RR 18, Temp 101.5 F

Physical exam

No apparent distress

Gi: Soft, tender to deep palpation in epigastrium and RUQ, BS+

Rest of exam is unrevealing

Cbc WNL, BMP shows slight AKI and slight metabolic anion gap acidosis.

UA and LFTs again unremarkable

What is your differential diagnosis?

The ED isn’t sure, but worried about a lot of things that show up on CT, so they get a CT abdomen/pelvis with IV and oral contrast. It shows….

…thrombus noted in the superior mesenteric vein extending into the portal veins with some subsegmental occlusion noted. There is a small foci of air associated with thrombus. No pneumoatosis and no free air…

What should you do next?

Mesenteric vein thrombosis

JORGE JO KAMIMOTO MD PGY 2 IM

Pathogenesis Primary vs Secondary

Secondary in 75% of cases

Conditions associated with mesenteric vein thrombosis

History and work up

Age of presentation 40 -60 years mostly males

50% personal or family history of blood clots

75% of patients symptomatic for 48 hours or more at presentation

Common presenting symptoms: Mid abdominal pain disproportionate to exam

Nausea, vomiting, diarrhea, constipation

Poor outcome predictors:

Fever (infection vs ischemia), Hemodynamic instability, Peritoneal signs

Diagnosis

Usually made non invasively

Plain abdominal films

Abnormalities 50 -75 % cases

Nonspecific findings: dilated bowel loops, ileus and mucosal edema

Can help to detect perforation

CT abdomen with contrast Diagnostic modality of choice

90% accuracy

Bowell wall thickening more than 10mm 90% accuracy for infarction

Work up

Work up

JAK2V617F screening in SVT patients without typical hematological MPN features identified MPN in 17.1% and 15.4% of screened BCS and PVT patients, respectively. It can be concluded that besides bone marrow histology, screening for JAK2V617F is an important diagnostic tool to detect MPN in these patients and should be performed in all patients with abdominal vein thrombosis as part of the standard diagnostic work-up.

Relationship between PNH and Splanchnic vein thrombosis

Flow cytometry, using monoclonal antibodies against CD55 and CD59, may identify PNH in a subclinical state when clinical and laboratory signs of hemolysis are still lacking.

Treatment

Can be managed medically if no evidence of infarction

Anticoagulation with LMWH should be started immediately after diagnosis If there is no need for invasive procedures start anticoagulation with

oral agent

Continue anticoagulation for 6 months if known reversible condition

Anticoagulation for life in pro-thrombotic states and idiopathic

Broad spectrum antibiotics if evidence of infection

Supportive care includes:

Bowel rest, NS suction, fluids/electrolyte/blood product replacement

References