Experience on Diagnosis and Treatment of Strangulated Intestinal Obstruction Caused by Mesentery Vein Thrombosis on Account of Portal Hypertension

doi:10.4236/eng.2013.510B074

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Engineering, 2013, 5, 368-370

http://dx.doi.org/10.4236/eng.2013.510B074 Published Online October 2013 (http://www.scirp.org/journal/eng)

Experience on Diagnosis and Treatment of Strangulated

Intestinal Obstruction Caused by Mesentery Vein

Thr ombosis on Account of Portal Hypertension*

Songbing He, Xinguo Zhu#

Department of General Surgery the First Affiliated Hospital of Soochow University, Suzhou, China

Email: #[email protected]

Received 2013

ABSTRACT

In the present study, to investigate diagnosis and treatment of strangulated intestinal obstruction caused by mesentery

vein thrombosis on account of portal hypertension, the data in twelve patients with this disease from 1998 to 2008 were

analyzed. All patients presented abdominal pain and vomiting and were confirmed strangulated intestinal obstruction

caused by mesentery thrombosis with operation. In this group, nine patients underwent part of small intestine excision,

and three patients underwent open-closed operation because of the whole small intestine necrosis caused by intensive

mesentery thrombosis. Five patients died after operation. The diagnosis of strangulated intestinal obstruction caused by

mesentery thrombosis was difficult because of the slow disease processes and severe outcomes. It is necessary to take

some measures to get over the dangers duration after operation.

Keywords: Portal Hypertension; Vein Thrombosis; Intestinal Obstruction

1. Introduction

The morbidity ratio of strangulated intestinal obstruction

caused by vena mesenteric thrombopoiesis pre-operation

is much lower than that of post-operation regarding to

portal hypertension [1]. In resent 10 years, there are 162

cases of strangulated intestinal obstruction treated in our

hospital, among which 12 cases (about 7.4%) are induced

by thrombopoiesis on account of portal hypertension. Here

is the analysis of pathogenesis, diagnosis and treatment

on the disease.

2. Clinical Mater ial s

1) General information

The clinical sample contains twelve cases in which pa-

tients suffer mesentery vein thrombosis caused by portal

hypertension induced by posthepatitic cirrhosis. In this

group, every patient has a history of type B hepatitis for

above five years with the symptoms of splenomegaly and

hypersplenism. Five patients have a history of upper di-

gestive tract hemorrhage. Portal hypertension is proved

only in two cases by ultrasound, CT scan or/and inter-

ventional radiography (Figure 1), while ascites in the

patients were detected in eight cases. In this group,

there is only one case in Grade A, eight cases in Grade

B and three cases in Grade C classified by Child-Pugh

Grading.

Figure 1. Interventional radiography of mesentery vein

thrombosis.

Supported by: Science an d Technology Research Proje ct of in Science

and Technology Bureau of Suzhou City, China (No. SYS201220);

Grants from Medical Science and Technology Development Founda-

tion, Jiangsu Province Department of Health, China (No.H201209).

#Corresponding author.

S. B. HE, X. G. ZHU

369

2) Clinical manifestation

Among twelve cases, there are six patients presenting

irregular or continuous fever of unknown origin between

38.5˚C to 40.2˚C lasting for ten to forty-one days. All

twelve cases have the symptoms of nausea, vomiting,

epigastric gas pains, but only six cases have intense bel-

lyache. The physical sign of per itonitis could be detected

in seven patients, and haemic ascites is punctured out

from abdominal cavity.

Pneumatics in enteric cavity is displayed in abdo minal

X-ray plains of all the cases, besides small amounts of

gas-fluid level without obviously distended ansa intersti-

nalis can be seen in only three cases.

3) Results

All cases have to be received emergency exploratory

laparotomy. The whole mesostenium which is diffusingly

dotted with bleeding points of unequal size are thickened

and congested extensively. Among them, two cases are

taken to emergency exploratory laparotomy without ob-

vious improvement after conservative treatment in twen-

ty-four hours. Nine cases underwent partial resection of

the small intes tine du e to small int estine, while three cases

underwent open-close operation because of full length

small intestine and part of colon necrosis simultaneously

with a great quantity of haemic ascites. Five cases died

after operation in which three cases are widespread

thrombosis and two cases are liver function failure after

partial resection of the small intestine. Also we can get

the immunohistochemistry result of the patients after

operation (Figure 2).

3. Discussion

The venous thrombosis is concerned with lesion of vas-

Figure 2. Immunohistochemistry of mesentery vein throm-

bosis.

cular endothelial cell, adhering and assembling of plate-

lets, low serum antithrombase, and alteration of haemo-

dynamics [2,3]. Posthepatitic cirrhosis is a kind of hepat-

ic sinusoid cirrhosis, which has augmented resistance of

blood flow returning to liver resulting in hypertension in

vena mesenteric and torpidity of blood flow. Meanwhile

a bulk of fatty acid, amino acids and carbohydrate ab-

sorbed in small intestine are accumulated in mesostenium

which increase the viscosity. Chronic portal hypertension

plus ischemic and hypoxia of endothelial cells of vena

mesenteric could damage endothelial cells unavoidably.

The function of single platelet won’t be weakened, in-

stead, adhering and assembling of platelets will augment

due to the necessity of compensation in spite of the in-

creasing demolition of platelet leading by splenomegaly

and hypersplenism. In addition, patients of hepatic cirr-

hosis with low level of hepatic protein synthesis are in

the hypercoagulable state owing to the dysfunction of

antiprothrombin [4]. In a word, mesostenium in portal

system is prone to thrombopoiesis influenced by all the

factors mentioned above.

The disor der of hemorheology been secondary to throm-

bopoiesis in vena mesenteric which leads to completely

interruption of venous blood flow will result in the simi-

lar circumstance in the arterial mesenteric, and strangu-

lated intestinal obstruction will emerge ultimately [5,6].

It is different from acute volvulus with the interruption of

blood flow both in arterial and vena mesenteric simulta-

neously causing the typically manifestation such as in-

tense abdominal pain, nausea and vomiting. The symp-

tom of intense abdominal pain occurs only in seven cases

in this group, and all the others have non-specificity ma-

nifestations such as abdominal discomfort, nausea and

vomiting. Furthermore, two cases attempted to adopt con-

servative treatment before exploratory laparotomy. Thus,

the clinical manifestation of strangulated intestinal ob-

struction caused by vena mesenteric thrombopoiesis on

account of portal hypertension is so insidious that it is

difficult t o ha ve t imely and accura te diagnosis. C ontinuous

fever and general toxic symptoms with leucocytes count

of more than 20 × 109 per liter would emerge attachin g to

vena mesenteric thrombopoiesis. What’s more, ascites

even jaundice and alimentary tract hemorrhage could be

detected if infective pylephlebitis occurs in addition to

the aggravation of infective symptoms. Accordingly, it is

necessary to take ultrasound or CT scan for patients of

portal hypertension with the symptoms of continuous fev-

er, abdominal pain, abdominal distention, nausea and vo-

miting. Thrombopoiesis in vena mesenteric, thickened me-

sostenium, and haemic ascites can be considered as suf-

ficient indications of emergency exploratory laparotomy

[7]. Actually there are three cases in this group dying

from extensive thrombopoiesis owing to delayed diagno-

sis.

S. B. HE, X. G. ZHU

370

Since the residual embolic mesostenium is the original

cause of fever and thrombopoiesis after emergency ex-

ploratory laparotomy, pathologic mesostenium has to be

resected thoroughly when removing the necrosis intestine

for patients of the strangulated intestinal obstruction caused

by vena mesenteric thrombopoiesis on account of portal

hypertension. Meanwhile, adjunctive therapy such as pro-

tection of hepatic function, nutritional support, diureses,

and proper blood transfusion calls for more attention as

most patients in emergency operations occupying a he-

patic inadequacy state of Grade B even C.

4. Acknowledgements

We would like to express our thanks to the anonymous

reviewers for their suggestions, which helped to improve

this paper.

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