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\begin{document}

\title{Fatal superior mesenteric vein thrombosis due to acute Appendicitis in
an elderly patient}



\author[1]{Houssem Harbi}%
\author[1]{Issam Jedidi}%
\author[2]{Nozha Toumi}%
\author[3]{L Chtourou}%
\author[2]{Nizar Kardoun}%
\affil[1]{Habib Bourguiba Hosp}%
\affil[2]{University of Sfax Faculty of Medecine of Sfax}%
\affil[3]{Hedi Chaker Hospital}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\selectlanguage{english}
\begin{abstract}
Superior mesenteric vein thrombosis (SMVT) is a rare complication of
acute appendicitis. It has no specific clinic manifestation.
Anticoagulation, antibiotics and surgery are the main treatment pillars.
We report herein a case of an 86-years-old women treated for acute
appendicitis complicated with SMVT and massive pulmonary embolism.%
\end{abstract}%



\sloppy


\textbf{Title:} Fatal superior mesenteric vein thrombosis due to acute
Appendicitis in an elderly patient

\textbf{Short Title:} Superior mesenteric vein thrombosis due to acute
Appendicitis

\textbf{Key words:} Mesenteric Vein - Thrombosis - elderly -
Anticoagulation - Mortality.

\textbf{Authors:}

\textbf{Houssem Harbi \textsuperscript{1}} (MD)

Associate Professor in General Surgery

\textbf{Issam Jedidi \textsuperscript{1}} (MD)

Specialist in General Surgery

\textbf{Nozha Toumi \textsuperscript{2}} (MD)

Associate Professor in Radiology

\textbf{Lassaad Chtourou \textsuperscript{3}} (MD)

Associate Professor in Gastro enterology

\textbf{Nizar Kardoun \textsuperscript{1}} (MD)

Associate Professor in General Surgery

\textbf{Institution}

\begin{enumerate}
\tightlist
\item
  General Surgery Department - Habib Bourguiba Hospital \& Research
  Laboratory LR21ES04 -- University of Sfax -- Tunisia
\item
  Radiology Department - Habib Bourguiba Hospital \& Research Laboratory
  LR21ES04 -- University of Sfax -- Tunisia
\item
  Gastro enterology Department -- Hedi Chaker Hospital -- University of
  Sfax -- Tunisia
\end{enumerate}

\textbf{Corresponding Author:}

\begin{itemize}
\tightlist
\item
  Houssem Harbi
\item
  Mail address:\emph{houcem\_harbi@hotmail.fr}
\item
  Postal address : Dr Harbi Houssem - Imm Rayene Km4 Route Lafrane Sfax
  Tunisia
\item
  Phone number: +216 58~127~423
\end{itemize}

\textbf{Specific author contributions:}

\begin{itemize}
\tightlist
\item
  Houssem harbi: collecting and interpreting data, and drafting the
  manuscript
\item
  Issam Jedidi: collecting and interpreting data, and drafting the
  manuscript
\item
  Nozha Toumi: collecting and interpreting data
\item
  Lassaad Chtourou: collecting and interpreting data
\item
  Nizar Kardoun: collecting and interpreting data
\end{itemize}

\textbf{All authors approved the final draft submitted.}

\textbf{Financial support:} none

\textbf{Potential competing interests:} all authors declare that they
have no conflict of interest.

\textbf{Text word count:} 895

\textbf{Number of figures:} 2

\textbf{Number of tables:} 0

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy

\textbf{Abstract:}

Superior mesenteric vein thrombosis (SMVT) is a rare complication of
acute appendicitis. It has no specific clinic manifestation.
Anticoagulation, antibiotics and surgery are the main treatment pillars.
We report herein a case of an 86-years-old women treated for acute
appendicitis complicated with SMVT and massive pulmonary embolism.

\textbf{Manuscript}

\textbf{Fatal superior mesenteric vein thrombosis due to acute}

\textbf{Appendicitis in an elderly patient}

\textbf{INTRODUCTION}

Superior mesenteric vein thrombosis (SMVT) caused by acute appendicitis
is a very rare

entity. It may cause varying degrees of intestinal wall lesions as
oedema, congestion,

and eventually necrosis. It is essential to make an early diagnosis,
although its non-specific

clinical presentation, so as to initiate specific treatment as soon as
possible to avoid fatal

outcome. Indeed, the mortality rate of SMVT associated with
intra-abdominal infection is

relatively high and ranges from 30 to 50\% \textbf{{[}1{]}} .

\textbf{CASE REPORT}

An 86 years old woman, with history of hypertension, diabetes and
dyslipidaemia, was

operated for acute appendicitis confirmed by abdominal ultra-sound.
Intraoperative

exploration (through a McBurney incision) revealed a gangrenous appendix
with oedematous

and slightly cyanotic ileo-caecal junction. The unusual aspect of the
latter was assigned to local inflammation and usual appendectomy was
performed. Three days later, she presented

dyspnea and hypoxemia. Abdomino-thoracic angioscan showed a proximal
pulmonary

embolism with a circumferential thickening of the caecum and terminal
ileum without any

local collection. Heparin therapy was started and antibiotics were
prescribed. Seven days later, she had a new abdominal scan because of
abdominal distension with diffuse abdominal

tenderness, fever and hyper leucocytosis. It suggested a mesenteric
venous infarction as it

showed superior mesenteric vein thrombosis (Figures 1 and 2) associated
to circumferential

thickening and default enhancement of the caecum and terminal ileum
(Figure 1). The patient

had a respiratory failure and died before we could perform intestinal
resection.

\textbf{DISCUSSION}

Pylephlebitis is defined as a septic thrombosis of the portal vein. It
may be caused by infection of organs that drains into the portal venous
system. This physio pathologic mechanism was proven in the 70s. The most
common involved abdominal infection is colonic diverticulitis, then
appendicitis and cholecystitis \textbf{{[}2{]}} . The incidence of
septic thrombophlebitis of the porto-mesenteric veins due to acute
appendicitis was close to 0.4\% before 1950. With

improvements of antibiotics and surgery, it has become nowadays much
rarer \textbf{{[}3{]}} .

Symptoms of pylephlebitis are non-specific. Abdominal signs like
abdominal tenderness or

distention and ascites may occur with increasing ischemia. In severe
cases with trans mural

infarction and bowel gangrene, peritoneal signs such as rebound
tenderness or rigidity should

be observed \textbf{{[}4{]}} .

Abdominal computed tomography (ACT) is the most reliable diagnostic
imagery. It could find out the primary source of infection, the extent
of pylephlebitis, and eventually liver abscesses. Color flow Doppler
ultrasound is also a sensitive test for studying the patency of the
portal venous system \textbf{{[}5, 6{]}} .

During acute appendicitis with SMVT, thrombi are formed rapidly with
increasing

inflammation, possibly leading to intestinal oedema, congestion, and
eventually necrosis.

Consequently, SMVT should be suggested in case of acute appendicitis
with functional

occlusion and unusual appearance of the ileo-cecal junction during
appendectomy particularly

in elderly and debilitated patients like in our case.

SMVT can be managed either surgically or by nonoperative approaches.
Patients with signs of peritoneal irritation need often surgery for
intestinal resection and eventually a thrombectomy. Nonoperative
management of SMVT includes both invasive (pharmacologic thrombolysis)
and non-invasive procedures.

When SMVT is slowly progressing, the intestinal blood flow remains
almost intact thanks to

the development of collaterals so that intestinal necrosis could be
avoided. Therefore,

conservative treatment using anticoagulants should be attempted first.

Anticoagulation therapy for pylephlebitis may reduce septic embolization
to the liver from

infected portal thrombi and thus would prevent liver abscess formation.
However, its use

remains a controversial issue, as its benefit has not been clearly
demonstrated. Some authors

\textbf{{[}7{]}} reported that heparin adjunction is not necessary for
pylephlebitis when the primary

disease such as appendicitis or diverticulitis is well controlled. In
this case, anticoagulation

therapy should not be started initially.

Some authors recommended systematic anticoagulation on the presumption
of an

hypercoagulable state in addition to the risk of process extension which
could lead to an

enteric ischemia \textbf{{[}8{]}} . In fact, our patient had probably a
hypercoagulable state as she presented

a postoperative pulmonary embolism and she had a SMVT most likely from
the beginning but

unfortunately, misdiagnosed. Furthermore, as heparin therapy was started
lately (3 days after

appendectomy) she presented fatal intestinal infarction.

Nevertheless, there is still lack of data concerning the optimum
duration of anticoagulation. A

short duration seems reasonable in case of septic SMVT without any
intestinal infarction or

embolization \textbf{{[}9{]}} .

Some authors suggested that interval laparoscopic appendectomy must be
performed 2-3 months after treatment with antibiotics and
anticoagulants\textbf{{[}10, 11{]}} . However, if the inflammation
cannot be

controlled by conservative treatment, surgical removal of the primary
lesion is mandatory even without signs of intestinal necrosis.

Despite anticoagulation proven efficiency, intravascular infusion of
thrombolytics seems efficient with higher rate of recanalization.
Furthermore, pharmacologic thrombolysis of clot would facilitate a
possible thrombectomy \textbf{{[}12{]}} .

In conclusion, septic pylephlebitis is rarely reported as a complication
of acute appendicitis.

Due to its uncommon and non-specific symptoms, it is often misdiagnosed
and thus still

associated with high mortality rate. Old patients with pain in the right
iliac fossa, rarely related to acute appendicitis, should be explored by
an abdominal angioscan not only because of possible abscessed caecal
tumor but also to look for pylephlebitis and SMVT that is more common in
elderly patient \textbf{{[}13{]}} . The role of anticoagulation therapy
remains controverted but it seems mandatory in case of elderly or
debilitated patients who are at high risk of thrombosis

extension and intestinal infarction.

\textbf{REFERENCES}

1. Singh P, Yadav N, Visvalingam V, Indaram A, Bank S.. Diagnosis and
management. Am J

Gastroenterol 2001;96:1312-3.

2. Bockmeyer J, Taha-Mehlitz S, Heeren N, Ristic S, Metzger J, Gass JM.
Jejunal Diverticulosis Probably Leading to Pylephlebitis of the Superior
Mesenteric Vein.

Case Rep Surg. 2020 Sep 16;2020:2343218.

3. Chang TN, Tang L, Keller K, Harrison MR, Farmer DL, Albanese CT.
Pylephlebitis,

portal-mesenteric thrombosis, and multiple liver abscesses owing to
perforated appendicitis. J

Pediatr Surg 2001;36:E19.

4. Brunaud L, Antunes L, Collinet-Adler S et al. Acute mesenteric venous
thrombosis : case

for non operative management. J VascSurg. 2001;34(4):673-679.

5. Balthazar EJ, Gollapudi P. Septic thrombophlebitis of the mesenteric
and portal veins : CT

imaging. J Comput Assist Tomogr 2000;24:755--60.

6. Nishimori H, Ezoe E, Ura 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(2):173--6.

7. Lee KW, Choi YI. Superior mesenteric vein thrombosis accompanied with
severe

appendicitis. Korean J Hepatobiliary Pancreat Surg 2014;18:101-103

8. Chang PK, Hsu KF, Yu JC, Chang YM, Chan DC, Liao GS. Acute
appendicitis with

superior mesenteric vein septic thrombophlebitis : case report. J Chin
Med Assoc. 2012 Apr ;

75(4) : 187-9.

9. Karam MM, Abdalla MF, Bedair S. Isolated superior mesenteric venous
thrombophlebitis

with acute appendicitis. Int J Surg Case Rep. 2013;4(4):432-4.

10. Takehara K, Miyano S, Machida M, Kitabatake T, Fujisawa M, Kojima K.
Superior

mesenteric vein thrombosis as a complication of acute appendicitis :
report of a case. Clin J

Gastroenterol 2013 6:269--273

11. Kerr L, White RZ, Au J. Appendicitis with superior mesenteric vein
thrombosis. Surgery. 2021 Aug 14:S0039-6060(21)00760-1.

12. Kaplan JL, Weintraub SL, Hunt JP, Gonzalez A, Lopera J, Brazzini A.
Treatment of

superior mesenteric and portal vein thrombosis with direct thrombolytic
infusion via an

operatively placed mesenteric catheter. Am Surg. 2004 Jul;70(7):600-4.

13. Nainani V, Oo J, Ban EJ. Superior mesenteric vein thrombus as a
complication of acute appendicitis. ANZ J Surg. 2021
Jul;91(7-8):1631-1632.

\textbf{Figures legends}

\textbf{Figure 1:} Coronal view of CT scan showing a 51mm superior
mesenteric vein thrombosis (yellow arrow) with circumferential
thickening and default enhancement of the caecum (black arrow heads).
There is also a surrounding (peri-colic) fat infiltration in the right
iliac fossa (white arrow heads)

\textbf{Figure 2:} Sagittal view of CT scan showing superior mesenteric
vein extensive thrombosis yellow arrow).\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Image-2/Image-2}

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