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Acute Mesenteric Ischemia Caused by Venous Thrombosis in a Patient With Leiden V Factor Mutation
Isquemia mesentérica aguda por trombosis venosa en paciente portador de mutación Leiden del factor V
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=> "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Isquemia mesentérica aguda por trombosis venosa en paciente portador de mutación Leiden del factor V" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 986 "Ancho" => 1314 "Tamanyo" => 297757 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intraoperative findings: venous ischemia (a) and venous thrombosis in the mesenteric section (b).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Mesenteric venous thrombosis is a rare cause of acute abdomen, representing only 5%–15% of cases of acute mesenteric ischemia.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Its diagnosis is difficult if not accompanied by clinical suspicion.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Factor V (proaccelerin) is a co-enzyme that acts on factor X of the blood coagulation cascade, enabling it to activate thrombin, which interacts with fibrinogen to convert it into fibrin, a main component involved in blood clotting. Under normal conditions, activated C protein inhibits the action of factor <span class="elsevierStyleSmallCaps">V</span>. Leiden mutation is a variation of factor <span class="elsevierStyleSmallCaps">V</span> that makes it insensitive to activated C protein, producing a state of hypercoagulability.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Factor V Leiden mutation is the most frequent cause of thrombophilia in Caucasians, and its prevalence without a history of thrombosis is 2%–7%, which increases to 20%–50% in patients with venous thrombosis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a 55-year-old male patient with a history of obesity (body mass index 30.6<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>), deep vein thrombosis of the lower extremities and heterozygous for factor <span class="elsevierStyleSmallCaps">V</span> Leiden, who came to the emergency room due to vomiting and sudden-onset diffuse abdominal pain for one week that was associated with diarrhea but no bleeding. He had been on a diet during the previous 6 weeks and had lost 6<span class="elsevierStyleHsp" style=""></span>kg. Upon physical examination, the patient had no fever and was haemodynamically stable, although he was pale and perspiring, with diffuse abdominal pain and distension, absence of peristalsis and guarding upon palpation. His workup showed leukocytosis with neutrophilia (92%), hemoglobin 13.9<span class="elsevierStyleHsp" style=""></span>g/dL, glucose 181<span class="elsevierStyleHsp" style=""></span>mg/dL, creatinine 1.1<span class="elsevierStyleHsp" style=""></span>mg/dL, CK 56<span class="elsevierStyleHsp" style=""></span>U/L, amylase 70<span class="elsevierStyleHsp" style=""></span>U/L and CRP 7.9<span class="elsevierStyleHsp" style=""></span>mg/dL. Simple radiographs of the chest and abdomen were normal. An emergency computed tomography (CT) scan revealed thrombosis of the superior mesenteric vein and branches, along with congestive small bowel loops with wall thickening, rarefaction of the fat at the mesenteric root, and free fluid. The spleno-portal axis was permeable, and no pneumatosis or pneumoperitoneum were observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Emergency surgery revealed ischemia of a 60<span class="elsevierStyleHsp" style=""></span>cm section of the jejunum (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a), which was resected and reconstructed with manual end-to-end anastomosis. After division of the mesojejunum, we observed thrombosis of the mesenteric vessels (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b). During the immediate postoperative period, the patient received anticoagulation therapy with heparin at a daily dose of 6000<span class="elsevierStyleHsp" style=""></span>IU according to the patient's weight; he was monitored by the hematology unit until his discharge 6 days later.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Intestinal ischemia secondary to venous thrombosis is more difficult to diagnose and treat than arterial thrombosis, which usually has an insidious course and nonspecific clinical signs.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> The altered venous return causes edema of the intestinal wall, affected microvascular perfusion, loop distension and, finally, infarction of the affected bowel. Mesenteric venous thrombosis is frequently secondary to other processes like neoplasms, hypercoagulability syndromes, pancreatitis, abdominal trauma, severe dehydration or <span class="elsevierStyleItalic">polycythaemia vera</span>.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In our case, the main risk factor was factor V Leiden mutation, which increases the risk for thrombosis between 7 and 80 times depending on whether it is heterozygous (50% altered factor <span class="elsevierStyleSmallCaps">V</span>) or homozygous (100%), and obesity was an additional risk. Other influential circumstances are oestrogens (contraception, pregnancy), antiphospholipid antibody or smoking.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnosis of mesenteric venous thrombosis is often delayed and based on clinical suspicion and CT studies with intravenous contrast in arterial and venous phases, whose findings correlate with the severity of the process.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Frequent findings include the vascular thrombosis itself, or indirect signs of intestinal complications, such as segmental thickening of the bowel wall, intestinal pneumatosis, portal venous gas, free fluid or increased uptake of the mesenteric fat.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The therapeutic objective, in addition to support measures and antibiotic therapy, is to re-establish the venous blood flow. The treatment of choice is early anticoagulation with unfractionated heparin,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> and surgery is indicated in patients with peritoneal irritation or suspicion of intestinal ischemia. Heparinisation can be stopped or reverted with protamine if reoperation is necessary. In our case, anticoagulation was initiated in the immediate postoperative period and continued after discharge.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the cases with Leiden mutation, anticoagulation is not recommended for life unless there have been 2 episodes of thrombosis or other associated risk factors. The most important prognostic factor in mesenteric venous thrombosis is the duration of the symptoms before diagnosis. In the study by Alvi et al.,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> patients with more than 3 days of symptoms presented a higher need for laparotomy (83 vs 20%; <span class="elsevierStyleItalic">P</span>=.018) and higher mortality (50 vs 7%; <span class="elsevierStyleItalic">P</span>=.06).</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, mesenteric venous thrombosis is a disease to consider in the differential diagnosis of acute abdomen in patients that present states of hypercoagulability. CT scan is the test of choice for early diagnosis, and the main treatment is anticoagulation, although surgery is indicated if there is peritonism or signs of ischemia.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interests</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare having no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of Interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sánchez Corral J, Martínez Casas I, Huertas Riquelme JL, David Alvarado J, Camacho Lozano J. Isquemia mesentérica aguda por trombosis venosa en paciente portador de mutación Leiden del factor V. Cir Esp. 2015;93:672–674.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1091 "Ancho" => 995 "Tamanyo" => 147363 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computed tomography image: free fluid, congestion of the small bowel loop and rarefaction of mesenteric fat.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 986 "Ancho" => 1314 "Tamanyo" => 297757 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intraoperative findings: venous ischemia (a) and venous thrombosis in the mesenteric section (b).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute mesenteric venous thrombosis: Improved outcome with early diagnosis and prompt anticoagulation therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 22 | 1 | 23 |
| 2024 September | 63 | 3 | 66 |
| 2024 August | 42 | 3 | 45 |
| 2024 July | 45 | 5 | 50 |
| 2024 June | 40 | 3 | 43 |
| 2024 May | 35 | 5 | 40 |
| 2024 April | 37 | 12 | 49 |
| 2024 March | 68 | 5 | 73 |
| 2024 February | 79 | 14 | 93 |
| 2024 January | 137 | 11 | 148 |
| 2023 December | 102 | 6 | 108 |
| 2023 November | 95 | 15 | 110 |
| 2023 October | 143 | 5 | 148 |
| 2023 September | 61 | 6 | 67 |
| 2023 August | 65 | 2 | 67 |
| 2023 July | 128 | 3 | 131 |
| 2023 June | 74 | 9 | 83 |
| 2023 May | 132 | 4 | 136 |
| 2023 April | 122 | 3 | 125 |
| 2023 March | 90 | 5 | 95 |
| 2023 February | 83 | 4 | 87 |
| 2023 January | 86 | 9 | 95 |
| 2022 December | 67 | 9 | 76 |
| 2022 November | 59 | 13 | 72 |
| 2022 October | 63 | 14 | 77 |
| 2022 September | 69 | 12 | 81 |
| 2022 August | 62 | 15 | 77 |
| 2022 July | 45 | 11 | 56 |
| 2022 June | 38 | 9 | 47 |
| 2022 May | 48 | 6 | 54 |
| 2022 April | 57 | 12 | 69 |
| 2022 March | 64 | 11 | 75 |
| 2022 February | 73 | 8 | 81 |
| 2022 January | 83 | 10 | 93 |
| 2021 December | 57 | 11 | 68 |
| 2021 November | 55 | 10 | 65 |
| 2021 October | 100 | 10 | 110 |
| 2021 September | 76 | 7 | 83 |
| 2021 August | 46 | 11 | 57 |
| 2021 July | 64 | 8 | 72 |
| 2021 June | 57 | 11 | 68 |
| 2021 May | 47 | 12 | 59 |
| 2021 April | 128 | 53 | 181 |
| 2021 March | 89 | 18 | 107 |
| 2021 February | 55 | 10 | 65 |
| 2021 January | 41 | 9 | 50 |
| 2020 December | 53 | 10 | 63 |
| 2020 November | 53 | 16 | 69 |
| 2020 October | 46 | 8 | 54 |
| 2020 September | 47 | 10 | 57 |
| 2020 August | 38 | 10 | 48 |
| 2020 July | 34 | 7 | 41 |
| 2020 June | 53 | 14 | 67 |
| 2020 May | 43 | 9 | 52 |
| 2020 April | 24 | 2 | 26 |
| 2020 March | 34 | 1 | 35 |
| 2020 February | 37 | 8 | 45 |
| 2020 January | 38 | 11 | 49 |
| 2019 December | 53 | 9 | 62 |
| 2019 November | 54 | 6 | 60 |
| 2019 October | 65 | 8 | 73 |
| 2019 September | 48 | 4 | 52 |
| 2019 August | 30 | 3 | 33 |
| 2019 July | 37 | 7 | 44 |
| 2019 June | 87 | 22 | 109 |
| 2019 May | 199 | 52 | 251 |
| 2019 April | 91 | 35 | 126 |
| 2019 March | 19 | 15 | 34 |
| 2019 February | 22 | 5 | 27 |
| 2019 January | 20 | 9 | 29 |
| 2018 December | 19 | 4 | 23 |
| 2018 November | 20 | 7 | 27 |
| 2018 October | 52 | 4 | 56 |
| 2018 September | 78 | 6 | 84 |
| 2018 August | 31 | 0 | 31 |
| 2018 July | 30 | 2 | 32 |
| 2018 June | 29 | 1 | 30 |
| 2018 May | 51 | 2 | 53 |
| 2018 April | 35 | 0 | 35 |
| 2018 March | 33 | 4 | 37 |
| 2018 February | 30 | 2 | 32 |
| 2018 January | 22 | 5 | 27 |
| 2017 December | 16 | 1 | 17 |
| 2017 November | 28 | 2 | 30 |
| 2017 October | 21 | 1 | 22 |
| 2017 September | 23 | 2 | 25 |
| 2017 August | 24 | 4 | 28 |
| 2017 July | 23 | 0 | 23 |
| 2017 June | 30 | 5 | 35 |
| 2017 May | 39 | 4 | 43 |
| 2017 April | 14 | 2 | 16 |
| 2017 March | 24 | 6 | 30 |
| 2017 February | 85 | 3 | 88 |
| 2017 January | 21 | 6 | 27 |
| 2016 December | 39 | 9 | 48 |
| 2016 November | 23 | 5 | 28 |
| 2016 October | 70 | 4 | 74 |
| 2016 September | 143 | 10 | 153 |
| 2016 August | 51 | 2 | 53 |
| 2016 July | 23 | 2 | 25 |
| 2016 June | 32 | 19 | 51 |
| 2016 May | 10 | 6 | 16 |
| 2016 April | 12 | 9 | 21 |
| 2016 March | 13 | 4 | 17 |
| 2016 January | 0 | 1 | 1 |
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