Acute superior mesenteric vein thrombosis leading to bowel ischemia in a patient with morbid obesity

Abinesh1*, Deepa. S2, Subathra Devi. M 3, Mahalakshmi4

1Critical care Technician, ICU, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

2ANS, Critical care, Kauvery Hospital, Cantonment ,Trichy, Tamil Nadu

3Nurse Educator, Kauvery Hospital, Cantonment ,Trichy, Tamil Nadu

4Nursing Superintendent, Kauvery Hospital, Cantonment. ,Trichy, Tamil Nadu

*Correspondence

Abstract

A 32-year female with morbid obesity who had previously undergone laparoscopic sleeve gastrectomy, presented with acute gastrointestinal and respiratory symptoms following an episode of diarrhea. Further evaluation revealed superior mesenteric vein thrombosis with congested small bowel loops. Despite initial conservative management and therapeutic anticoagulation, she developed progressive abdominal symptoms and features suggestive of intestinal ischemia. Emergency exploratory laparotomy was subsequently performed. Postoperatively she required intensive care unit support, anticoagulation, antimicrobial therapy, wound and stoma management and nutritional support. Her clinical condition gradually improved and she was subsequently stabilized and prepared for discharge with appropriate follow-up advice.

Key words: Acute gastrointestinal; Antimicrobial therapy; Superior Mesenteric Vein Thrombosis (SMVT)

Introduction

Superior Mesenteric Vein Thrombosis (SMVT) is an important cause of mesenteric venous obstruction that can result in intestinal congestion impaired bowel perfusion and eventually bowel ischemia. Early recognition and appropriate anticoagulation are essential to prevent progression and complications. However, patients who develop clinical deterioration or evidence of bowel ischemia may require urgent surgical intervention.

Case presentation

A 32-year female with a history of morbid obesity and status post laparoscopic sleeve gastrectomy on 29 May 2026, presented to the emergency department with a 3days history of diarrhea following consumption of juice from an outside. This was followed by severe upper abdominal pain radiating to the back, vomiting, abdominal distension, constipation and breathing difficulty.

Relevant Clinical Findings

Social History: She does not have any social history of smoking, Tobacco and alcohol.

Allergies: No known medicine or environmental allergies.

Past Medical History

  • She has a known case of DM on medical management.
  • Morbid obesity BMI – 50

Past Surgical History: She underwent laparoscopic sleeve gastrectomy on 29 May 2026.

Physical Examinations

On arrival at our emergency room, she is conscious and oriented.

PR74b/min
BP110/60 mm of hg
Temp98'F
SpO298% in RA
RR20/min
GCSE4 V5 M6
CVSS1S2 (+)
RSBAE (+), bilateral NVBS (+)
P/ASoft, diffuse tenderness present.
CNSNFND

Relevant Investigation

Markable Investigation

NoInvestigation NameResult
1Hemoglobulin7.7 to 9.2g/dl
2WBC11470 to18910 cells/cu mm
3Platelet189000 to 205000 cels /cumm
4Sodium131mmol/L to 127mmol/L
5Potassium3.8 mmol/L to 3.7mEq/L

CECT Abdomen Report on 16.06.2026

Edematous jejunal bowel loops with circumferential wall thickening and adjacent mesenteric haziness with thrombosis of portal vein, superior mesenteric vein and splenic veins. No oral leak. Gallbladder calculus. Mild ascites.

CT Scan Pulmonary Angiogram done on 18.06.26

Cardiomegaly with dilated pulmonary artery. No obvious evidence of pulmonary thromboembolism. Bilateral minimal pleural thromboembolism. Bilateral ligation of bilateral lower lobes. Congestive hepatomegaly and mild splenomegaly, Moderate ascites.

USG Bed Side done on 21.06.2026

Portal vein and SMV appears thrombosed, Cholelithiasis splenomegaly dilated peristaltic bowel loops with minimal ascites, and bilateral minimal pleural effusion.

Doppler done on 03.07.26

No evidence of DVT of right lower limb, no evidence of superficial thrombophlebitis

Diagnosis

  • Mesenteric venous ischemia leading to bowel gangrene
  • Morbid obesity – BMI 50- Post bariatric surgery status
  • DM

Management and Treatment

CECT abdomen revealed superior mesenteric vein thrombosis with congestion of the small bowel loops, which were initially viable. The patient was admitted to the critical care unit for close monitoring and further management. Based on the clinical findings and investigation results, a vascular surgeon’s opinion was obtained, and treatment was continued as advised. Non-Invasive Ventilation (NIV) was initiated to manage respiratory distress. Echocardiography revealed dilatation of the right atrium (RA) and right ventricle (RV), while CT pulmonary angiography showed no evidence of pulmonary embolism. Initially, conservative management was initiated with bowel rest, intravenous fluids, broad-spectrum antibiotics, electrolyte correction, Total Parenteral Nutrition (TPN), and therapeutic anticoagulation with intravenous unfractionated heparin, titrated according to the Activated Partial Thromboplastin Time (APTT). Despite these measures, the patient developed progressively worsening abdominal pain and increased nasogastric tube output. Repeat clinical assessment and Doppler ultrasonography raised suspicion of evolving intestinal ischemia. Considering the clinical deterioration, informed consent was obtained, and emergency exploratory laparotomy was performed. Following surgery, the patient was managed in the ICU with ventilatory support as required, anticoagulation, broad-spectrum antibiotics, nutritional support, and close monitoring.

Surgical Management 22.06.2026

Laparoscopy+ Laparotomy + Small bowel resection and double barrel stoma done under GA.

Initial laparoscopy one 12mm optiport one 5mm port-ischemic bowel gangrenous segment noted hence converted to laparotomy.

Nursing Management

  • Continuous monitoring: Closely monitored vital signs, spo2, respiratory status, GCS, urine output and abdomen pain, distension, bowel sounds and signs of worsening intestinal ischemia.
  • Anti coagulation: Administer IV unfractionated heparin as prescribed and monitor APTT bleeding manifestation, HB and platelet count.
  • Fluid and electrolytes management: Maintain strict intake output charting and replace fluid /electrolyte losses, especially with high output stoma.
  • Stoma care: Assess stoma color, viability, position, skin condition and output provide regular stoma care and monitor for retraction or other complications.
  • Nutritional management: Maintain TPN as prescribed initially and gradually support oral /enteral nutrition support according to tolerance.
  • Pain management: Assesses pain regularly and administer prescribed analgesics while monitoring response.
  • Mobilization: Encouraged gradual mobilization and ambulation as tolerated to prevent complications of immobility.
  • Patient education: Educated to the patient attender and patient regarding stoma care, adequate hydration, nutrition, wound care, anticoagulant therapy and warning signs of dehydration and bleeding.
  • Postoperative wound care: Performed aseptic wound dressing, observe for redness, discharge, wound dehiscence and infection.

Outcome

Her condition gradually improved, and she was successfully weaned off ventilatory and NIV support before being transferred to the ward for further care.

Discharge medications

Name of the Drug Dose Route Frequency
Inj. Meropenam1gmIVTDS
Inj. Pantocid 40mgIV TDS
Inj. Metrogyl500mgIV TDS
Inj. Heparin 5000unitsIV Q6H
Neb. Duolin + Budecort TDS
Inj. Lesuride25mgIVTDS
Tab. Shelcal500mg OD
Ensure powder DM2Scoops TDS
Sac. Electral powder -- TDS
Inj. Albumin correction - - -
Inj. Pottassium chloride correction -- -
Inj. Actrapid correction - - -

Discussion

Superior mesenteric vein thrombosis is a serious condition that can reduce blood flow from the intestine and lead to bowel ischemia. Early diagnosis and treatment with anticoagulation are important to prevent complications. In this case, conservative management was initially started but worsening abdominal pain and increased nasogastric tube output raised suspicion of intestinal ischemia, requiring emergency laparotomy. Postoperative ICU care, anticoagulation, antibiotics, and nutritional support helped the patient recover gradually. This case highlights the importance of early diagnosis, close monitoring, and timely surgical intervention in patients with mesenteric vein thrombosis.

Conclusion

Superior mesenteric vein thrombosis can progress to intestinal ischemia despite initial conservative management. Early diagnosis, appropriate anticoagulation, close clinical monitoring and timely surgical intervention when deterioration occurs are essential for achieving a favorable outcome. Comprehensive postoperative wound, stoma, nutritional and anticoagulation care further contribute to successful recovery.

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