key: cord-0890187-2udbydei
authors: Singh, Balraj; Kaur, Parminder; Maroules, Michael
title: Splanchnic vein thrombosis in COVID-19: A Review of Literature
date: 2020-09-29
journal: Dig Liver Dis
DOI: 10.1016/j.dld.2020.09.025
sha: 298e9709bf811e4701a85249402feecf2e2ee3dc
doc_id: 890187
cord_uid: 2udbydei

nan

. Splanchnic vein thrombosis (SVT) including portal, mesenteric, splenic vein thrombosis and the Budd-Chiari syndrome, is a manifestation of unusual site venous thromboembolism. SVT usually occurs in association with cirrhosis, liver malignancy or in patients with inherited or acquired thrombophilia [5] . Limited literature is available regarding SVT in COVID-19. We did an extensive literature review on COVID-19 associated SVT. We searched PubMed for this literature review using search terms 'COVID-19 and splanchnic vein thrombosis, 'COVID-19 and portal vein thrombosis', 'COVID-19 and mesenteric vein thrombosis', COVID-19 and Budd-Chiari syndrome', COVID-19 and hepatic vein thrombosis' and 'COVID-19 and splenic vein thrombosis'. All the case reports with COVID-19 associated SVT so far were reviewed, and relevant data was abstracted from these studies. COVID-19 diagnosis was made by PCR assay except in one patient it was negative (suspected COVID-19).

The clinical features, laboratory values and outcome are summarized in Table 1 [6] [7] [8] [9] [10] [11] . We found total of six patients. The median age of patients was 58 years (range 27-79 years) and 50% were male. Presenting symptoms were vomiting, abdominal pain, diarrhea, fever, shortness of breath, jaundice and altered mental status. None of the patients had cirrhosis or hepatocellular cancer. Work up done to rule out known associated inherited or acquired prothrombotic states in each case is outlined in table 1. One of the patients was diagnosed with essential thrombocytosis (myeloproliferative neoplasm), a known risk factor for SVT. The diagnosis of SVT was made by computed tomography. SVT can occur as a presenting feature or a late complication of COVID-19. Five patients were diagnosed on day 1 of presentation and one patient was diagnosed on day 6. Portal vein was involved in all the patients, superior mesenteric in two while splenic vein and hepatic vein in one. One patient had concurrent superior mesenteric and jejunal artery thrombosis. All patients were started on anti-coagulation. Out of six, two patients died.

The exact pathological mechanism leading to the complication of SVT in COVID-19 is not well understood at present, possibilities include -viral infection of the endothelial cell leading to diffuse endothelial inflammation or increased procoagulant factors like factor VIII, von Willebrand factor, fibrinogen or virus induced cytokine storm leading to coagulation and fibrinolysis activation. [12] [13] [14] Additional explanations for the hypercoagulability may be the presence of high numbers of prothrombotic circulating microvesicles which are cytoplasmic microparticles stemming from platelets or monocytes and Neutrophil external traps (NETs) released from activated neutrophils, constitute a mixture of nucleic DNA, histones and nucleosomes. [14] The cause of SVT should be investigated systematically. The goal of treatment of acute SVT is to recanalize the obstructed veins, which will prevent complications-intestinal infarction, liver injury and portal hypertension. Clinicians should be aware of this unusual manifestation of COVID-19 so that prompt and appropriate interventions can be undertaken if it is suspected or confirmed. 

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The looming storm: Blood and cytokines in COVID-19

Acute upper limb ischemia in a patient with COVID-19. Hematology/Oncology and Stem Cell Therapy

COVID-19 Infection and Arterial Thrombosis: Report of three cases

Cerebral and Splanchnic Vein Thrombosis: Advances, Challenges, and Unanswered Questions

Portal vein thrombosis in a patient with COVID-19

Portal Vein Thrombosis in a Patient With COVID-19

Acute Portal Vein Thrombosis in SARS-CoV-2 Infection: A Case Report

Hepatobiliary and Pancreatic: A fatal case of extensive splanchnic vein thrombosis in a patient with Covid-19

Arterial and venous abdominal thrombosis in a 79-year-old woman with COVID-19 pneumonia

Small bowel ischemia and SARS-CoV-2 infection: an underdiagnosed distinct clinical entity

Acute Mesenteric Ischemia in Severe Coronavirus-19 (COVID-19): Possible Mechanisms and Diagnostic Pathway

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wnl within normal limits, CT computed tomography, PNH paroxysmal nocturnal hemoglobinuria, CMV cytomegalovirus, EBV Epstein-Barr virus, HSV herpes simplex virus, ANA anti-nuclear antibody, ANCA anti neutrophil cytoplasmic antibody, AMA anti mitochondrial antibody, ASMA anti smooth muscle antibody, anti-LKM-1 anti liver kidney microsomal antibody, NR not reported, SIH still in hospital at the writing of respective manuscript, AC anti-coagulation, Reference values-Wbc 4-10 10 9 /L)/, Hb 12-15 g/dL, platelets 150-350 x 10 3 µL