P3943 - Double Trouble in a Stable Cirrhotic: Simultaneous Superior and Inferior Mesenteric Vein Thrombosis, Recent Variceal Banding, and the Endless Anticoagulation Dilemma

Ivan Mogollon, MD¹, Taiwo Ajani, MD², Ismael Cantú, MD¹, Kuang-Wei Chang, MD¹
1University of Texas Rio Grande Valley, Edinburg, TX; 2University of Texas Rio Grande Valley, McAllen, TX

Introduction: Cirrhosis induces complex alterations in hemostasis, shifting the balance between bleeding and thrombosis. These changes involve reduced hepatic synthesis of procoagulant and anticoagulant factors, thrombocytopenia due to hypersplenism, and compensatory elevations in factor VIII and von Willebrand factor. Endothelial dysfunction, and impaired fibrinolysis contribute to a fragile yet prothrombotic state. This "rebalanced" hemostatic system may predispose even patients with compensated cirrhosis to thrombotic complications. While portal vein thrombosis is a known complication, concurrent thrombosis of both the superior and inferior mesenteric veins is Infrequently observed. We present a case of compensated cirrhosis complicated by SMV and IMV thrombosis, despite normal platelet count and mildly elevated INR, illustrating the paradoxical hypercoagulable state in cirrhosis.

Case Description/

Methods: A 65-year-old woman with alcoholic liver cirrhosis (Child-Pugh A, MELD-Na 10) presented with two weeks of progressive lower abdominal pain radiating to the back. The pain was cramping, sharp, and rated 8/10. Patient was unable to identify any specific triggers or alleviating factors and denied GI bleeding or bowel habit changes. A week prior, she had undergone band ligation for large esophageal varices. Labs showed INR 1.3, platelets 111,000, normal AST/ALT. CT revealed hypodense SMV and IMV with inflammatory changes. MRI confirmed nonocclusive thrombi in both veins. There was no hepatocellular carcinoma or infection. Hypercoagulability workup was unremarkable. She was started on full-dose enoxaparin, later transitioned to apixaban, with symptom improvement.

Discussion: Simultaneous thrombosis of the SMV and IMV is a rare complication of cirrhosis, particularly in compensated cirrhosis without portal vein involvement. Even in patients with compensated cirrhosis, the risk of thrombotic events is high due to the complex hemostatic balance. In this case, a comprehensive hematologic workup ruled out inherited or acquired hypercoagulable states, suggesting that local factors such as altered venous flow and endothelial dysfunction likely contributed to thrombosis. Anticoagulation posed bleeding risks, particularly in the setting of recent variceal banding but the need to prevent complications outweighed the risk. This case underscores the importance of individualized risk-benefit analysis when managing thrombosis in cirrhotic patients, despite being clinically stable and compensated.


Figure: Figure 1. Abdominal CT showing filling defects in both the superior and inferior mesenteric vein consistent with concomitant mesenteric venous thrombosis. Surrounding inflammatory changes in the adjacent mesentery are also noted.


Figure: Figure 2. Abdominal MRI with contrast (T1 sequence), demonstrating hypointense nonocclusive thrombus in superior and inferior mesenteric vein.

Disclosures:
Ivan Mogollon indicated no relevant financial relationships.
Taiwo Ajani indicated no relevant financial relationships.
Ismael Cantú indicated no relevant financial relationships.
Kuang-Wei Chang indicated no relevant financial relationships.

Ivan Mogollon, MD¹, Taiwo Ajani, MD², Ismael Cantú, MD¹, Kuang-Wei Chang, MD¹. P3943 - Double Trouble in a Stable Cirrhotic: Simultaneous Superior and Inferior Mesenteric Vein Thrombosis, Recent Variceal Banding, and the Endless Anticoagulation Dilemma, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.