Upper gastrointestinal bleeding in superior mesenteric vein thrombosis
Editor – We have read the case report and accompanying literature review entitled ‘Upper gastrointestinal bleeding in superior mesenteric vein thrombosis’ by Phyu et al with great interest.1 Although we agree with the authours review of the literature, we feel there is more to consider in cases like this based on our experiences in a tertiary hepatology centre.
In the discussion points it is rightly pointed out that recanalisation of the superior mesenteric vein in the acute setting is vital. However, the authors go on to argue that mechanical thrombectomy ‘should only be considered if the patient's condition continues to deteriorate despite anticoagulation’ and surgery should be considered if there is evidence of bowel ischaemia.
It is important to note that surgical intervention is associated with worse short and long-term outcomes and prolonged hospital stays.2 Intestinal infarction and bowel necrosis necessitating surgery is an endpoint that would indicate end-organ damage and treatment failure and therefore should be avoided.
As is the case with other acute, thromboembolic conditions such as pulmonary emboli and ischaemic strokes, it is recognised that medical thrombolysis may be able to achieve recanalisation more rapidly and improve outcomes in carefully selected patients.3,4
Experience at a tertiary centre with thrombolysis in acute splanchnic vein thrombosis (SVT) has recently been published.5 The 22-patient case series highlights the potential role of tissue plasminogen activator and local clot dissolution therapy in preventing surgery. This approach may be indicated in patients with features of uncompensated bowel ischaemia as evidenced by clinical (eg poor resolution of abdominal pain, peritonism), biochemical (eg progressive lactataemia) or radiological (eg bowel loop dilatation or oedema) grounds. A step-wise thrombolysis protocol and early referral to a specialist hepatology centre should have a role in the treatment protocol for patients with SVT.
- © Royal College of Physicians 2020. All rights reserved.
References
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- Phyu WP
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- Benmassaoud A
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