Forensic Science, Medicine, and Pathology

, Volume 8, Issue 4, pp 475–476

Mesenteric venous thrombosis

Authors

    • Discipline of Anatomy and Pathology, School of Health SciencesThe University of Adelaide
Lessons from the Museum

DOI: 10.1007/s12024-011-9302-1

Cite this article as:
Byard, R.W. Forensic Sci Med Pathol (2012) 8: 475. doi:10.1007/s12024-011-9302-1

Clinical presentation

A 78-year-old woman was referred from a peripheral hospital where she had been admitted 2 weeks previously with anorexia, abdominal discomfort, nausea and vomiting. On admission to the tertiary care center she was noted to be in congestive cardiac failure with peripheral and pulmonary edema, and bilateral pleural effusions. There were also ischemic changes on her electrocardiograph (ECG). Medical therapy was undertaken, however, she collapsed and died unexpectedly 2 days later.

Autopsy findings

At autopsy the body was that of an elderly Caucasian female of around the stated age. Her height was 175 cm, weight 84 kg, and body mass index (BMI) 27. There was cardiomegaly (615 gms) with evidence of left ventricular failure (congestion and edema of the lungs with pleural effusions). Bilateral pulmonary thromboemboli were present obstructing both the right and left pulmonary arteries. An additional finding was thrombosis of the superior mesenteric vein with ischemic changes within the jejunum (Fig. 1).
https://static-content.springer.com/image/art%3A10.1007%2Fs12024-011-9302-1/MediaObjects/12024_2011_9302_Fig1_HTML.jpg
Fig. 1

Museum specimen showing ischemic discoloration of the jejunum with dissection of the mesenteric vessels revealing thrombotic occlusion of the superior mesenteric vein

Cause of death

Bilateral pulmonary thromboembolism complicating mesenteric venous thrombosis.

Museum reference

This case, # 24686, can be located at the Hans Schoppe Museum of Pathology at the School of Medical Sciences, Medical School North, The University of Adelaide, Frome Rd, Adelaide, SA, Australia.

Discussion

Intestinal ischemia occurs when the blood supply to the intestine falls below that necessary to maintain normal tissue metabolic processes, oxygenation and integrity. The American Gastroenterological Association classifies intestinal ischemia into three broad categories of acute mesenteric ischemia, chronic mesenteric ischemia and ischemic colitis [1]. Mesenteric venous thrombosis falls within the first group and accounts for 1.5–6.2% of cases of acute mesenteric ischemia [2].

Mesenteric venous thrombosis is an uncommon disorder and may have quite subtle clinical features, resulting in delay in diagnosis and identification only at the time of autopsy, as occurred in the reported case; it is likely that the symptoms in the weeks preceding the fatal collapse from pulmonary thromboembolism were due to mesenteric pathology. Clinical symptoms often consist of nonspecific and intermittent abdominal pain for days or weeks with anorexia and diarrhea [3] and may be precipitated by a viral infection [2]. Less than 10% of patients have histories under one day [4]. Mortality rates vary from 19 to 23% and have been directly linked to delays in formulating the diagnosis [2, 5].

While mesenteric venous thrombosis may be idiopathic, there is a strong association with conditions that are recognized as predisposing to thrombosis elsewhere, including infection, malignancy, abdominal trauma, inflammatory bowel disease, cirrhosis and hypercoagulable states such as protein C and S deficiencies, antithrombin III deficiency, factor IX deficiency, polycythemia rubra vera, and thrombocytosis [4, 6] (Table 1). Sixty-seven percent of patients in one study had hypercoagulable states [2]. Focal mesenteric venous thrombosis may be found in cases of mechanical obstruction to venous blood flow from volvulus or herniation.
Table 1

Conditions predisposing to mesenteric venous thrombosis [5, 8, 9]

General

 Hypercoagulable states

 Obesity

 Malignancy

 Oral contraceptive use

 Congestive cardiac failure

 Autoimmune disease

Local

 Abdominal trauma (blunt and penetrating)

 Post surgical (e.g. splenectomy)

 Inflammation e.g. inflammatory bowel disease, pancreatitis, abscess, peritonitis

 Portal hypertension/cirrhosis

 Hypersplenism

An interesting feature of the reported case is the presence of venous thrombosis at two sites: the pulmonary and the mesenteric vasculature. The occurrence of multifocal areas of thrombosis has been commented on before in these cases [5, 6], raising the possibility of underlying thrombophilic disorders in individuals who develop mesenteric venous thrombosis. Although not present in the current case, obesity also predisposes to venous thromboses and pulmonary thormboembolism, associated with reduced physical activity and an intrinsic hypercoagulable state [7]. An additional factor that may play a role in intra-abdominal venous thrombosis is the possibility of increased intra-abdominal pressure in obesity compressing the portomesenteric system and causing stasis and thrombosis [5].

In conclusion, mesenteric venous thrombosis is a rare entity that may not be identified until autopsy, although clinical diagnoses are improving with the use of modern imaging techniques such as computerised tomographic (CT) scanning [8]. A clue to its presence may be a history of coagulopathy or previous thrombotic episodes. It may occur without causing frank intestinal infarction [6]. When found at autopsy the examination should include careful documentation of predisposing conditions and also associated comorbidities such as congestive cardiac failure and cardiomegaly (that were present in the reported case). Consideration should be given to testing for hereditary thrombophilias.

Acknowledgments

Dr. R. Williams is acknowledged and thanked for performing the original autopsy.

Copyright information

© Springer Science+Business Media, LLC 2011