P2530 - Beyond the Colon: A Rare Vascular Complication of Diverticulitis

Halim Bou Daher, MD¹, Erica C. Becker, MD, MPH², Mike Giacaman, MD³
1SSM Health Saint Louis University Hospital, Saint Louis, MO; 2SSM Health Saint Louis University Hospital, St. Louis, MO; 3Saint Louis University, Saint Louis, MO

Introduction:

Most cases of diverticulitis are mild to moderate in severity, but up to 12% of cases may include complications. The most common complications include abscess formation, peritonitis and perforation. A much rarer complication is the mesenteric vein thrombophlebitis.

Case Description/

Methods: Our patient is a 46-year-old female with known diverticulosis diagnosed on screening colonoscopy who presented with abdominal pain for 5 days. On arrival at the hospital, the patient had rigors, chills and was noted to be tachycardic. Initial work-up revealed a hemoglobin of 10.8, a white blood cell counts of 12.4, liver function tests slightly elevated and a total bilirubin of 2.2. CT scan of the abdomen with contrast showed diverticulitis of the sigmoid colon with associated thrombophlebitis of the inferior mesenteric vein and extending into the liver causing portal thrombophlebitis with air in the vein. The patient received a 5-day course of piperacillin - tazobactam and a continuous heparin infusion for anticoagulation. Blood cultures grew Escherichia coli and staphylococcus epidermidis and she was transitioned to ciprofloxacin and metronidazole. She was discharged home on levofloxacin, metronidazole and apixaban with plans to follow up with outpatient colonoscopy and sigmoid colon resection. Interestingly, the patient had work-up for hypercoagulability while inpatient and was found to be positive for lupus anticoagulants and decreased protein C, S and Antithrombin III levels in the setting of active thrombosis. On outpatient follow-up, patient’s repeat lupus anticoagulant panel was negative.

Discussion: As reported in previous case reports, IMV thrombophlebitis is a rare complication of diverticulitis. It is largely agreed that the mechanism is likely bacterial translocation in the venous system triggering an inflammatory and pro-coagulation state in the portal-mesenteric venous system. Patients are treated with antibiotics due to associated bacteremia. However, anticoagulation is a topic of discussion given the underlying mechanism. In our patient’s case, apixaban was prescribed due to concern for lupus anticoagulants. Previous studies, showed that patient with hypercoagulable states were treated with both antibiotics and anticoagulation compared to those with isolated portal thrombophlebitis. On the other hand, it appears that better outcomes have been associated with a combination of antibiotics and anticoagulants as per more recent publications.


Figure: CT scan of the abdomen in coronal view showing air in the portal vein in the left lobe of the liver


Figure: CT scan of the abdomen in axial view showing air in the portal vein in the left lobe of the liver

Disclosures:
Halim Bou Daher indicated no relevant financial relationships.
Erica Becker indicated no relevant financial relationships.
Mike Giacaman indicated no relevant financial relationships.

Halim Bou Daher, MD¹, Erica C. Becker, MD, MPH², Mike Giacaman, MD³. P2530 - Beyond the Colon: A Rare Vascular Complication of Diverticulitis, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.