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Mesenteric venous thrombosis(MVT) is responsible for approximately 5-15% of all cases of acute mesenteric ischemia(AMI) and difficult to diagnose at early terms. The diagnostic delay always occurs and is associated with high morbidity and mortality, new diagnostic strategies are needed. To report the early diagnosis of a superior mesenteric venous thrombosis(SMVT) without bowel necrosis in emergency department(ED).
A 33-year-old female patient was admitted to ED with periumbilial pain lasting for 4 days. Tracing back her history, the patient denied any significant systemic disease except contraceptive pill intake for 8 months. A general physical examination revealed periumbilial tenderness without peritoneal irritation signs and hyperactive bowel sound, other systems were normal. Her white blood cell count was 7,960/mm3, granulocyte proportion was 68.4%, plasma D-dimer values was 2.91mg/L FEU. Abdominal ultrasonography revealed cholecystic wall thickness was increased without cholelithiasis. Esomeprazole and anisodamine were administered intravenously, her abdominal pain was not relieved after antispasmodic therapy. She was suspected of having acute mesenteric venous thrombosis due to contraceptive pill intake and elevated D-dimer. The contrast enhanced abdominal CT scans was arranged immediately, which demonstrated thrombosis of the proximal portal superior mesenteric venous(SMV) and total occlusion of the proximal segment of SMV, no signs of intestinal ischemia were present.
The patient was admitted to the vascular surgery on 14 Mar 2016. Anticoagulation therapy was administered intravenously. Her abdominal pain was gradually improved and discharged after 10 days. a long-term therapy of rivaroxaban tablets after discharge. The patient was followed up after 50 days, computed tomography Angiography(CTA) after 1 month shown complete resolution of the SMV.
SMVT is a very rare abdominal emergency and easy to make an original misdiagnosis because of the lacking of characteristic clinical manifestations. Multi-detector row CTA is the current gold standard in the diagnosis of SMVT. Although CTA leads to an accurate diagnosis in many cases, early detection remains a persistent problem because of the lacking of early specific serum marker. In this case, the early accurate diagnosis is based on experience with increased awareness of SMVT. The plasma D-dimer test is an early serum marker of thrombosis and could be used for screening patients who have non-specific abdominal pain with possible SMVT. We aim to emphasize a new diagnostic strategies according to the literatures leading to early accurate diagnosis. In conclusion, We suggest that CTA should be early done in patients with acute repeated abdominal pain and positive D-dimer incorporating risk factors for thrombophilia.