肠系膜静脉血栓性静脉炎的影像学表现

Mesenteric Venous Thrombophlebitis: A Complication of Diverticulitis Rashmi Jayadevan, MSIV Albany Medical College Dr. Gillian Lieberman Outline  Our Patient  Diverticulitis  Pathogenesis  Complications  Unique Complication  Companion Cases  Back to our patient Our Patient J.S.: History  HPI  60 year-old male with one week history of nausea, vomiting, epigastric pain and intermittent diarrhea  Unable to tolerate PO intake except for clear liquids  PE: T 101  Labs: WBC-33,300, Mildly elevated LFT’s and Alk Phos  PMH  Adenocarcinoma of the lung, Hodgkin’s Lymphoma, MI, TIA, SBOx2, skin cancer, hyperlipidemia, HTN  Surgical Hx  Splenectomy, cholecystectomy, CABG, Mohs resection Our Patient J.S.: RUQ Doppler U/S • Antegrade minimally pulsatile flow consistent with with portal waveform • Confirms that ultrasound images included the portal vein BIDMC PACS Our Patient J.S.: RUQ U/S Echogenic filling defect in portal vein BIDMC PACS BIDMC PACS Our Patient J.S.: Portal Venous Flow Studies BIDMC PACS BIDMC PACS Non-Occlusive Portal Venous Thrombosis: •No wall to wall flow seen •Filling defect does not show signs of vascularity •Flow seen distal to thrombus Portal Venous Thrombosis: Differential Diagnosis Local Factors  Liver cirrhosis  Hepatobiliary Malignancy  Intra-abdominal infection  Diverticulitis  Pancreatitis  Appendicitis  IBD  Injury to portal vein  Splenectomy  Abdominal Surgery Systemic Factors  Inherited  Factor V Leiden  Protein C/S deficiency  Antithrombin III deficiency  Acquired  OCPs  Pregnancy  Malignancy  Myeloproliferative Disorders Hoekstra J, Jassen HA. Vascular liver disorders (II): portal vein thrombosis. The Netherlands Journal of Medicine. 2009. Febl; 67(2): 46-53 Lets continue on to see the next study that our patient received Our Patient J.S.: Portal Venous Thrombosis on CT Hypodense filling defect at the portal confluence BIDMC PACS Axial C+ CT Image Our Patient J.S.: Portal Venous Thrombosis on CT Thrombosis of posterior branch of right portal vein BIDMC PACS Axial C+ CT Image AJR Online: http://www.ajronline.org/cgi/content-nw/full/183/4/1055/FIG1 BIDMC PACS Coronal Reformatted C+ CT Thrombus at the portal vein/SMV confluence Our Patient J.S.: Portal Venous Thrombosis on CT But wait…there’s more! Our Patient J.S.: Diverticulitis on CT Diverticulosis of the sigmoid colon BIDMC PACS Axial C+ CT Image Fat strandin g Diffuse colonic wall thickening Our Patient J.S.: Complication of Diverticulitis on CT BIDMC PACS Axial C+ CT Image BIDMC PACS Coronal Reformatted C+ CT Image BIDMC PACS Axial C+ CT Image Thrombus in the Inferior Mesenteric Vein Our Patient J.S.: Complication of Diverticulitis on CT Diagnosis  Imaging Findings  Diverticulitis  Thrombosis of Inferior Mesenteric Vein  Thrombosis of Portal Vein  Air in Inferior Mesenteric Vein  Differential for Portal Venous Gas:  Bowel ischemia, thrombophlebitis, iatrogenic, IBD Diagnosis: Diverticulitis Complicated by Mesenteric Venous Thrombophlebitis Diverticular Disease  More prevalent in western countries  Prevalence increases with age  Younger than 40: 10%  80 or older: 50-70%  Terminology:  Diverticula: saccular outpouchings of mucosa and submucosa- most commonly in the sigmoid colon  Diverticulosis/diverticular disease: uninflamed diverticula  Diverticulitis: Inflammation of diverticulum or diverticula Pathogenesis of Diverticulosis Horton K M et al. Radiographics 2000;20:399-418 Pathogenesis of Diverticulitis Obstruction of the narrow neck Distension of the Sac Bacterial Overgrowth Vascular Compromise Micro Perforation and pericolic inflammation Jacobs D. N Eng J Med. 2007. Nov; 357(20) 2057-2066. Clinical Presentation of Diverticulitis  Clinical presentation: Can be sufficient to make diagnosis  Abdominal pain-Left lower quadrant  Fever  Leukocytosis  Peritoneal signs indicating complications  Imaging is important:  If the diagnosis is uncertain  If there is failure to improve clinically with empiric treatment  If there are signs of complications Imaging Characteristics of Diverticulitis: X-ray  Abdominal X-Ray:  Abdominal X-Ray is important in any patient with significant acute abdominal pain  R/O free air or obstruction  Uncomplicated diverticulitis does not have specific findings on X-ray  Findings on X-ray in complicated diverticulitis can include:  Pneumoperitoneum  Bowel obstruction  Ileus  Abnormal gas or soft tissue mass Sarba D, Longo EW. Diagnostic Imaging of Diverticulitis. J Clin Gastroenterol. 2008. Nov/Dec; 42(10): 1139-114 Imaging Characteristics of Diverticulitis: Contrast Enema Confined perforation or abscess Stollman N, Jeffrey BR. The Lancet 2004. Feb; 363: 631-639 Imaging Characteristics of Diverticulitis: Contrast Enema Intramural sinus tract Stollman N, Jeffrey BR. The Lancet 2004. Feb; 363: 631-639  CT with IV/oral contrast is now the modality of choice Air filled outpouchings Fat Stranding Signs of complication: peridiverticular abscess Colonic thickening Jacobs D. N Eng J Med. 2007. Nov; 357(20) 2057-2066 Imaging Characteristics of Diverticulitis: CT Complicated Diverticulitis Diverticulitis plus any of the following Abscess Perforation  Fistula Obstruction Mesenteric venous thrombophlebitis Now lets discuss the complication in this case: Mesenteric Venous Thrombophlebitis  Also termed Pyelephlebitis  Acute infection of the portal system from a primary gastrointestinal inflammatory source  Colonic diverticulitis  Appendicitis  IBD  Supporative pancreatitis  Pelvic Infections  Rare complication of diverticulitis  Thrombosis of IMV is especially rare  Mortality can be high Mesenteric Venous Thrombophlebitis Mesenteric Venous Thrombophlebitis: Anatomical Correlation  Why the Inferior Mesenteric Vein (IMV) in Diverticulitis?  Inferior mesenteric vein drains the descending and sigmoid colon Cichoz-Lach et al.: http://www.jpp.krakow.pl/journal/archive/0808_s2/articles/16_article.html Pathogenesis of Mesenteric Venous Thrombophlebitis  Clinical Presentation:  Depends on the location and severity of primary inflammatory process  Can be very nonspecific  Fever  Chills  Upper abdominal pain  Leukocytosis  Review of 22 cases of pylephlebitis caused by diverticulitis, 30% of patients had localizing signs of a primary source of infection1 Clinical Presentation of Mesenteric Venous Thrombophlebitis Nonspecific 1. Balthazar EJ, Gollapudi P. J Comput Assist Tomogr 2000. 24(5) Imaging is very important for diagnosis!  Imaging CT is modality of choice CT findings can include  Localizing the primary source of infection  Involvement of the mesenteric branches and portal vein  Intravascular air  Peripheral or central thrombi  Intrahepatic abnormalities, i.e. abscess Imaging Characteristics of Mesenteric Venous Thrombophlebitis Companion Patient #1: 34 year-old male with pylephlebitis secondary to diverticulitis of sigmoid colon Inflammation of mesentery and air in peripheral branches of IMV Air in IMV Balthazar EJ, Gollapudi P. J Comput Assist Tomogr. 2000. 24(5): 755-760 Companion Patient #1:  Follow up CT 7 days Later Thrombus in IMV Portal Vein Thrombosis Balthazar EJ, Gollapudi P. J Comput Assist Tomogr. 2000. 24(5): 755-760 Other Imaging Modalities of Mesenteric Venous Thrombophlebitis  Selective angiography: Filling defect in the lumen during the venous phase  Contrast Enema: Colovenous fistula may be seen  Doppler Ultrasound can demonstrate portal venous thrombosis Now lets discuss a complimentary case Companion Patient # 2: Thrombophlebitis of SMV and Portal Vein  16 year old male presents with fever, nausea, vomiting and leukocytosis  U/S images on hospital day 9  Hospital Day 9: U/S and CT showed thrombus in portal vein and superior mesenteric vein RUQ U/S: White arrowheads show thrombus and thickened extrahepatic portal vein RUQ Doppler U/S: Antegrade continuous blood flow demonstrates patency of portal vein Images: H. Nishimori et al. Surg Today (2004) 34:173-176 Companion Patient # 2: Thrombophlebitis of Portal Vein and SMV on CT Axial C+ CT Image: White arrowhead shows thrombus of the portal vein with extension into the SMV Image: H. Nishimori et al. Surg Today (2004) 34:173-176 Companion Patient # 2: Appendicitis on CT Axial C+ CT Image: Black arrow shows abscess caused by appendicitis Image: H. Nishimori et al. Surg Today (2004) 34:173-176 Discussion of Companion Patient # 2  Abscess formation from appendicitis contributed to thrombophlebitis of the SMV and portal vein  Similar pathogenesis as thrombophlebitis of the IMV seen in diverticulitis  Appendicitis was previously a more common cause of this complication  Advances in antibiotic treatment and improved surgical techniques has decreased the incidence greatly H. Nishimori et al. Surg Today (2004) 34:173-176 Lets go back to our discussion of Mesenteric Venous Thrombophlebitis as a complication of diverticulitis Companion Patient # 3: Hepatic Complications of Mesenteric Venous Thrombophlebitis  Hepatic Complications  Hepatic Abscesses: Pyelephlebitis can extend into the portal vein and into the hepatic parenchyma  Commonly Isolated Bacteria1:  Escheriichia coli  Proteus mirabilis  Bacteroides fragilis  Aerobic gram-negative bacilli 1. Balthazar EJ, Gollapudi P. J Comput Assist Tomogr. 2000. 24(5): 755-760 * Hepatic Abscesses * * Thrombus in Portal Vein Axial C+ CT image: Balthazar EJ, Gollapudi P. Treatment of Mesenteric Venous Thrombophlebitis  Broad spectrum antibiotics that target  Enteric gram-negative bacilli  Anaerobes  Streptococcus species  Anticoagulation  Was controversial in the past but seems to be currently accepted  Surgery  Dependent on source on infection, clinical presentation of patient (i.e. sepsis), and complications Follow Up of Our Patient J.S.  Patient J.S. Hospital Course:  Anticoagulation: Started on Heparin drip and transitioned to Coumadin  Work up by Heme/Onc for coagulopathy was negative  Will continue Coumadin for 6 months  Antibiotics: Started on broad spectrum antibiotics  Vancomycin, Ciprofloxacin, Flagyl  Continued on oral Ciprofloxacin and Flagyl for 14 days  Bowel Rest Summary  Diverticulitis overview  Mesenteric Venous Thrombophlebitis = Pylephlebitis  Rare complication of diverticulitis  Imaging is crucial to diagnosis and prompt treatment  Air in mesenteric veins  Thrombus in mesenteric/portal veins  Hepatic Abscesses Acknowledgements  Dr. Jay Pahade, BIDMC Radiology  Dr. Gillian Lieberman, BIDMC Radiology  Maria Levantakis, BIDMC Radiology References  Balthazar EJ, Gollapudi P. Septic Thrombophlebitis of the Mesenteric and Portal Veins: CT Imaging. J Comput Assist Tomogr. 2000. 24(5): 755-760  Domajnko B, Kumar A, Salloum R. Mesenteric Venous Thrombophlebitis-Septic thrombophlebitis of the Inferior Mesenteric Vein: An Unusual Manifestation of Diverticulitis. The American Surgeon. 2007. April; 73: 404-406  Hoekstra J, Jassen HA. Vascular liver disorders (II): portal vein thrombosis. The Netherlands Journal of Medicine. 2009. Febl; 67(2): 46-53  Horton KM, Corl FM, Fishman EK. CT evaluation of the colon: Inflammatory disease. Radiographics 2000. March; 20(2): 399-418  Jacobs D. Clinical Practice: Diverticulitis. N Eng J Med. 2007. Nov; 357(20) 2057-2066.  Lee S, Kang YS, Astromoff N. Septic Thrombophlebitis of the Inferior Mesenteric Vein Associated with Diverticulitis CT Diagnosis. Clinical Imaging. 1996. 20:115-117  Molitch H. Septic Thrombophlebitis of the Inferior Mesenteric Vein Complicating Sigmoind Diverticulitis: CT Findings. AJR. 1996. Oct; 167: 1014-1016  Ng SS. Et al. Portal venous thrombosis in a Chinese patient with fulminant Crohns colitis: A case report with literature review. World J Gastroenterol. 2006. Sept; 12(34) 5582-5586.  Nishimori H. et al. Septic Thrombophlebitis of the Portal and Superior Mesenteric Veins as a Complication of Appendicitis: Report of a Case. Surg Today. 2004. 34: 173-176  Sarba D, Longo EW. Diagnostic Imaging of Diverticulitis. J Clin Gastroenterol. 2008. Nov/Dec; 42(10): 1139-114  Stollman N, Jeffrey BR. Diverticular Disease of the colon. The Lancet 2004. Feb; 363: 631-639 Mesenteric Venous Thrombophlebitis: A Complication of Diverticulitis Outline Our Patient J.S.: History Our Patient J.S.: RUQ Doppler U/S Our Patient J.S.: RUQ U/S Our Patient J.S.: Portal Venous Flow Studies Portal Venous Thrombosis:�Differential Diagnosis Slide Number 8 Our Patient J.S.: Portal Venous Thrombosis on CT Our Patient J.S.: Portal Venous Thrombosis on CT Slide Number 11 Slide Number 12 Our Patient J.S.: Diverticulitis on CT Our Patient J.S.: Complication of Diverticulitis on CT Our Patient J.S.: Complication of Diverticulitis on CT Diagnosis Diverticular Disease Pathogenesis of Diverticulosis Pathogenesis of Diverticulitis Clinical Presentation of Diverticulitis Imaging Characteristics of Diverticulitis: X-ray Imaging Characteristics of Diverticulitis: Contrast Enema Imaging Characteristics of Diverticulitis: Contrast Enema Imaging Characteristics of Diverticulitis: CT Complicated Diverticulitis� Slide Number 26 Mesenteric Venous Thrombophlebitis Mesenteric Venous Thrombophlebitis: Anatomical Correlation Pathogenesis of Mesenteric Venous Thrombophlebitis Clinical Presentation of Mesenteric Venous Thrombophlebitis Imaging Characteristics of Mesenteric Venous Thrombophlebitis Companion Patient #1: Companion Patient #1: Other Imaging Modalities of Mesenteric Venous Thrombophlebitis� Slide Number 35 Companion Patient # 2: Thrombophlebitis of SMV and Portal Vein Companion Patient # 2: Thrombophlebitis of Portal Vein and SMV on CT Companion Patient # 2: Appendicitis on CT Discussion of Companion Patient # 2 Slide Number 40 Companion Patient # 3: Hepatic Complications of Mesenteric Venous Thrombophlebitis Treatment of Mesenteric Venous Thrombophlebitis Follow Up of Our Patient J.S. Summary Acknowledgements References