Article, Traumatology

Acute portal venous thrombosis after blunt abdominal trauma

Case Report

Acute portal venous thrombosis after blunt abdominal trauma

Abstract

Portal venous thrombosis after blunt abdominal trauma is rarely encountered and carries high morbidity and mortality. We present a trauma patient with Liver laceration associated with acute portal vein and mesenteric vein thrombosis. A 26- year-old man presented to emergency department after motor vehicle accident with blunt abdominal trauma. His primary survey was unremarkable and secondary survey showed tenderness in the right hypochondrium. Computed tomogra- phy (CT) of the abdomen showed a grade III liver laceration involving segments VI and VII extending near the porta hepatis. He was hemodynamically stable and was monitored in a high-dependency unit. Follow-up CT of the abdomen after 1 week showed a liver laceration with thrombosis in portal vein extending into superior mesenteric vein. He was closely monitored for symptoms and signs of bowel congestion and ischemia. He was given prophylactic dose of heparin. He remained stable, and a repeat CT after 2 weeks showed partially resolved thrombus in portal vein and completely resolved thrombus in mesenteric vein. He was discharged on low-molecular-weight heparin for 6 weeks and aspirin for 3 months. portal vein thrombosis is a rare complication in patients with blunt abdominal trauma associated with liver injury. Periodic radiologic imaging is necessary while monitoring such type of patients. A high degree of suspicion for portal vein thrombosis is required especially when the liver laceration is closely related to portal hepatis.

Venous thrombosis after major trauma is commonly seen in deep veins of lower limb. Formation of thrombosis in major veins of the abdomen after abdominal trauma is relatively rare. Literature review showed few case reports of venous thrombosis in Inferior vena cava , portal vein, and mesenteric vein after blunt abdominal trauma [1-4]. We present a case of asymptomatic portal vein thrombosis (PVT) with associated thrombosis in superior mesenteric vein after blunt abdominal trauma.

A 26-year-old man was brought to the emergency department after being involved in a high-speed motor

vehicle accident. His primary survey was unremarkable. He had tenderness in the right hypochondrium on Abdominal examination. After initial assessment and resuscitation, a trauma series computed tomography (CT) scan was done, which revealed a full-thickness grade III liver laceration in segments VI and VII (Fig. 1) and seventh rib fracture on the right side. His laboratory data showed a hemoglobin of 144 g/L with marginal rise in Liver enzymes. Both the liver injury and rib fracture were treated conservatively and the patient was monitored in trauma high-dependency unit. Initial management consisted of strict bed rest, regular observation, repeated abdominal examination, and regular hematologic and Biochemical tests. The patient remained hemodynami- cally stable.

The CT scan of the abdomen repeated on day 7 demonstrated a full-thickness liver laceration in segments

VI and VII extending into the porta hepatis terminating adjacent to the right portal vein. An extensive filling defect was seen in the right portal vein, suggestive of occlusive thrombus (Fig. 2). There was also extension of this clot into the main portal vein and left portal vein that was nonocclusive. The clot was also visualized in the superior mesenteric vein and its main left branch extending toward the bowel (Fig. 3).

Fig. 1 Computed tomographic scan picture showing grade III liver laceration in segment VI.

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372.e2 Case Report

Fig. 2 Computed tomographic scan picture showing occlusive thrombus in right portal vein.

He was closely monitored with daily Blood lactate levels and stool charting for early detection of Bowel ischemia. The patient remained stable and asymptomatic. He was started on 5000 U of subcutaneous heparin thrice daily. Screening for an underlying thrombophilic disorder was negative, and no deep vein thrombosis was detected on Doppler ultrasound of lower limb Venous system.

Color Doppler ultrasound and repeat CT scan on day 16 showed a greatly resolved liver laceration with thrombosis in the right branch of the portal vein extending into the proximal part of the main portal vein, which was less extensive compared to the previous CT scan. Interestingly, there was no evidence of thrombosis within the superior mesenteric vein and its branches, but there was some degree of mesenteric fat stranding with prominent vessels sugges- tive of portal venous hypertension.

The patient was discharged on day 20 with 40 mg of low- molecular-weight heparin daily for 6 weeks and 100 mg of aspirin daily for 3 months.

Injuries to major abdominal veins after blunt abdominal trauma are rare, and they carry a high mortality rate. Isolated thrombus formation in abdominal veins after blunt abdom- inal trauma without Major injury to veins is very rare. Literature search revealed few case reports of venous thrombosis in IVC, portal vein, mesenteric veins, and renal vein after blunt abdominal trauma [1-4].

Duvoux et al [1] reported a case of PVT diagnosed 1 month after abdominal trauma on follow-up imaging. Gonzalez and colleagues presented a case of PVT 6 months after thoracoabdominal trauma [5]. In the present case, the PVT was detected 7 days after trauma on progress CT scan.

Occurrence of thrombosis in other intraabdominal veins is also reported. Fried et al [3] reported a case of superior mesenteric vein thrombosis after blunt abdominal trauma in a patient with primary Antiphospholipid syndrome. Clai- kens et al [6] presented a case of posttraumatic thrombosis

in inferior mesenteric vein with secondary venous conges- tion and ischemia of sigmoid colon. Campbell et al [4] described a case of acute thrombosis in IVC after blunt abdominal trauma.

The pathophysiologic mechanism of venous thrombosis in intraabdominal veins after trauma is multifactorial. The commonly suspected mechanisms are endothelial injury of the venous wall secondary to shear force and stasis of portal venous blood secondary to compression by periportal hematoma [4]. coagulation disorders are risk factors that were negative in the present case.

Thrombosis in the portal venous system can lead to secondary venous congestion and ischemia of bowel [6]. Blood lactate level is an early indicator of bowel sepsis due to mucosal ischemia and congestion. A complete search for risk factors such as Coagulation disorders and Hematologic diseases is also advised. Color Doppler ultrasonography is a feasible and cost-effective investigation for knowing the progress of PVT. They can progress to chronic portal hypertension if left untreated. A progress radiologic imaging should be viewed with a high degree of suspicion if there is associated liver laceration extending to porta hepatis as noted in the present case.

Treatment of acute PVT is mostly conservative unless associated with complications such as bowel infarction. Anticoagulation with heparin infusion is given provided there is no contraindication for anticoagulation and should be started early to prevent bowel infarction and secondary portal hypertension. therapeutic anticoagulation was not followed in the present case in view of associated liver laceration and hematoma.

In conclusion, PVT is a rare complication in patients with blunt abdominal trauma associated with liver injury. Periodic radiologic imaging is necessary while monitoring such type of patients. High degree of suspicion for PVT is required if the liver laceration is closely related to porta hepatis.

Fig. 3 Computed tomographic scan picture showing thrombus in superior mesenteric vein.

Case Report

Sri Vengadesh Gopal MS

Department of General Surgery

References

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Westmead Hospital Westmead, NSW 2145, Australia

E-mail address: [email protected]

Ian Smith MBBS, BSc(Med)

Department of General Surgery

Westmead Hospital Westmead, NSW 2145, Australia

Valerie Malka MIPH Department of Trauma, Westmead Hospital Westmead, NSW 2145, Australia

doi:10.1016/j.ajem.2008.07.021

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  2. Beaufort P, Perney P, Coste F, Masbou J, Le Bricquir Y, Blanc F. Post- traumatic thrombosis of the portal vein. Presse Med 1996;25(6):247-8.
  3. Fried M, Van Ganse W, Van Avermaet S. Mesenteric vein thrombosis triggered by blunt abdominal trauma in a patient with the primary antiphospholipid syndrome. Eur J Gastroenterol Hepatol 2002;14 (6):697-700.
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