Asymptomatic intestinal ischemia secondary to thrombosis of the spleno-mesenteric portal axis: Usefulness of laparoscopic approach for diagnosis and therapeutical decision. Case report and review of the literature

Abstract text (incl. references and figure legends)

CH:We present a case of a 77-year-old man complaining of mild abdominal pain and symptoms of intestinal obstruction, without fever nor nausea/vomiting, from 4 days before the admission to our emergency department. On past medical history ten years earlier a pulmonary thromboembolism treated with oral anticoagulants, currently treatment was acetylsalicylic acid.

CF:abdomen was tender, painful on palpation in the center- and left abdominal quadrants without signs of peritoneal irritation.

I/R:blood tests showed modest leukocytosis and an increase in CRP. On abdominal CT scan, the ileal jejunum walls appeared thick and poorly impregnated by contrast enhancement (fig 1).

D: mesenteric ischemia due to MSPVT

T:based on the radiological findings and the worsening of the symptoms the patient underwent surgery. Laparoscopic approach confirmed small bowel infarction plus free blood effusion. For this reason a changeover laparotomy was performed and a small bowel resection between jejunum and ileus was achieved (fig 2); due to the suffering of intestinal loops surgery was fulfilled with laparostomy. In the ICU, heparin was administered as a continuous infusion. Two days later, ileal jejunum anastomosis and wall synthesis were performed. On the 12th POD the patient was discharged with prescription for LMWH at anticoagulant dosage. One month later, he switched to oral anticoagulants.

D:Our patient was clinically stable with no hepatosplenomegaly nor guarding, despite a CT scan positive for intestinal infarction. The diagnosis of acute intestinal ischemia related to splanchnic trunk thrombosis is particularly troublesome due to its non-specific presenting sign and symptoms. The treatment"s choice requires a multidisciplinary approach. Emergency exploration by laparoscopy allows to reach the correct diagnosis, plus the real-time assessment of the intestinal infarction's extension,thus playing a double diagnostic and therapeutic role in those doubtful and tricky cases.

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