We present the case of a 67-year-old male with mesenteric venous thrombosis resulting in mesenteric angina, where early diagnosis made a favourable outcome possible through prompt anticoagulation and bowel rest. Mesenteric venous thrombosis is a relatively rare but important cause of bowel ischaemia, as a delay in diagnosis is associated with high morbidity and mortality. Early diagnosis through computed tomography scanning and subsequent treatment resulted in resolution of the thrombus with no long term sequelae.

Mesenteric venous thrombosis (MVT) is an unusual and non-specific cause of abdominal pain, accounting for only 10–15% of cases of mesenteric ischaemia. While MVT only accounts for an estimated 0.006% of all hospital admissions, it is probably more common when one considers the asymptomatic group of patients in whom MVT remains undiagnosed or is an incidental finding on computed tomography (CT) when investigating another intra-abdominal pathology. The high mortality rate at 30 days associated with delayed diagnosis makes it particularly important,¹ although MVT carries the best prognosis of all the causes of bowel ischaemia where it is diagnosed promptly. We report a case of superior mesenteric venous (SMV) thrombosis, followed by a discussion of MVT identification and management, with particular focus on bowel rest and anticoagulation.

An otherwise healthy 67-year-old Caucasian man presented with a 1 week history of abdominal pain starting almost immediately after eating and also associated with vomiting. He reported abdominal distension, but his bowels were opening normally with no abnormal stool. Notable medical history included deep venous thrombosis and three vessel coronary artery disease, for which he was on aspirin, pravastatin, atenolol, and amlodipine. There was no history of abdominal surgery. He enjoyed an active retirement, being a non-smoker and moderate drinker of alcohol.

The patient had upper abdominal tenderness in an otherwise soft but distended abdomen. Initial work up revealed only an elevated white cell count of 12.5×10⁹/l (normal range (NR) 4.0–11.0×10⁹/l) and C reactive protein of 101 mg/l (normal <10 mg/l), with a normal amylase 43 U/l (NR 0–100 U/L) and normal abdominal and chest radiographs. Lactate, a marker of bowel ischaemia, was elevated at 2.7 mmol/l (NR 0.60–2.0 mmol/l), but inorganic phosphate was measured at 0.64 mmol/l (NR 0.80–1.45 mmol/l).

Intravenous heparin was promptly started, with a target therapeutic activated partial thromboplastin time (APTT) ratio of between 2.0–3.0. A thrombophilia screen was negative. The patient was placed on nil by mouth.