S3877 Beyond the Colon: A Rare Vascular Complication of Diverticulitis

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 woman 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 workup 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. Computed tomography 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, inferior mesenteric vein 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.