A Case of Ileal Necrosis caused by Superior Mesenteric and Portal Vein Thrombosis associated with Protein S Deficiency

Kei Yonezawa, Jun Nakagawa, Toshihiko Gotoh, Motoko Harigai, Toshiki Kobayashi, Takuo Takehana, Masato Maeda, Toshiaki Moriki* and Tadashi Miyashita

Department of Surgery and Department of Pathology*, Shizuoka City Shizuoka Hospital

A 55-year-old man admitted in an emergency for acute abdominal pain was found in abdominal computed tomography (CT) to have a thrombotic obstruction in the superior mesenteric vein (SMV) and portal vein (PV). Ileal edema and ascites suggested ileal necrosis, necessitating an emergency laparotomy. The terminal ileum 20 cm to 70 cm from the ileocolic junction was necrotic, and intraoperative ultrasonography (US) showed thrombotic obstruction in the SMV. PV blood flow was decreased due to the PV thrombus and mainly supplied from the splenic vein. We resected the necrotic ileum and constructed an ileostomy. We conducted a second-look surgery 24 hours later to confirm the possible expansion of intestinal necrosis. Although the residual bowel was viable, about 50 cm of the terminal ileum was edematous and congested, necessitating additional resection. To prevent complete PV obstruction, we made linear venotomy on the SMV and PV and conducted PV thrombectomy. The postoperative course was satisfactory and anticoagulation therapy was continued using heparin followed by warfarin. The patient's protein S activity had been impaired up to 41.1%, which we concluded caused SMV and PV thrombosis due to a congenital deficiency.

Key words
superior mesenteric vein thrombosis, portal vein thrombosis, protein S deficiency

Reprint requests
Kei Yonezawa Department of Surgery, Shizuoka City Shizuoka Hospital
10-93 Otemachi, Aoi-ku, Shizuoka, 420-8630 JAPAN

Accepted
March 25, 2009

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