Edematous ileocecal valve due to mesenteric venous thrombosis.

A 59-year-old man with decompensated liver cirrhosis due to nonalcoholic steatohepatitis complained of vague abdominal pain and loose stools at a routine checkup. He had a history of repeated episodes of variceal bleeding treated endoscopically. Upon presentation, the patient was in no apparent distress and vital signs were normal. Mild tenderness to deep palpation in the right lower quadrant and splenomegaly were noted. Laboratory values remained unchanged from baseline, significant only for a slight increase in transaminases and mild thrombocytopenia.

Colonoscopy revealed an extremely edematous ileocecal valve (Figure 1a). Mild edema was also observed throughout the colon, with no signs of bleeding, ischemia, or inflammation. Computed tomography with contrast revealed mesenteric venous thrombosis (MVT) extending from the umbilical portion of the left portal vein to the splenic and superior mesenteric veins (Figure 1b). Significant colon edema was also observed, particularly in the cecum and ascending colon. No malignancies were noted. D-dimer was elevated to 7.1 mcg/mL. Results of an extensive hypercoagulability work-up were unremarkable. The patient was admitted for continuous intravenous infusion of heparin. Symptoms improved in 7 days and the patient was discharged on warfarin. Complete resolution of MVT was confirmed 5 months later.

Figure 1

a. Colonoscopy revealed an extremely edematous ileocecal valve and mild edema throughout the colon. 1b. Computed tomography with contrast revealed portomesenteric venous thrombosis (arrows) extending from the umbilical portion of the left portal vein to the splenic and superior mesenteric veins.

MVT is a rare cause of acute mesenteric thrombosis, accounting for about 3% of total cases and occurring in about 6% of cirrhotic patients [1, 2]. Subacute and chronic MVT can present with non-specific or no symptoms whatsoever [3]. Risk factors include portal hypertension, malignancy, abdominal inflammatory diseases, history of venous thromboembolism, and inherited or acquired thrombophilias [4]. Small bowel edema is observed in 39% of MVT cases and is associated with a higher bowel resection rate [5]. Large bowel edema is a much less common finding in cirrhosis and has not been reported in the context of MVT [6]. Cases not requiring surgery are treated with anticoagulation, intravenous fluids, and bowel rest. As MVT can present insidiously, imaging studies should be considered when bowel edema is noted on colonoscopy in a patient with relevant risk factors.