Presentation
The patient has been experiencing right upper quadrant (RUQ) pain for a long duration.
Patient Data
There is a filling defect noted in the superior mesenteric vein and inferior mesenteric vein, starting at the level of the inferior border of the L2 vertebral body and extending into the splenoportal confluence. It involves the proximal 3.5 cm of the splenic vein and the main portal vein, along with its branches, showing surrounding fat stranding. These findings suggest extensive venous thrombosis (bland thrombosis).
Multiple perihepatic collaterals are noted.
The remaining part of the splenic vein appears patent. The hepatic veins are well opacified by contrast.
The gallbladder shows multiple small, dense stones with no evidence of pericholecystic fat stranding or edema.
The right kidney shows a non-enhancing fluid density cortical lesion seen in the midportion, measuring about 3.6 x 3.5 cm.
The liver shows heterogeneous geographic areas of hypoattenuation (THAD).
A fat-containing umbilical hernia with a neck measuring about 0.7 cm is observed.
The visualized lung cuts show a well-circumscribed, non-enhancing lesion measuring about 2 x 1.2 cm, seen just inferior to the right main pulmonary vein, with a mean density of -10 HU, suggesting a pericardial cyst.
Case Discussion
In this non-cirrhotic patient with extensive mesenteric venous thrombosis, a hypercoagulability workup is a top priority.
An important feature that should be carefully evaluated is the enhancement of the thrombus to differentiate bland thrombus from tumoral thrombosis (which usually occurs in patients with hepatocellular carcinoma on a background of the cirrhotic liver).
The indolent course of abdominal pain in this patient and the presence of multiple perihepatic collaterals indicate a subacute clinical course.
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