# Idiopathic superior mesenteric vein thrombosis leading to gangrenous ileum: A case report

## TL;DR

A rare case of idiopathic superior mesenteric vein thrombosis led to severe bowel damage, highlighting the need for early diagnosis and treatment.

## Contribution

This case report emphasizes the importance of prompt diagnosis and multidisciplinary management in idiopathic SMVT.

## Key findings

- CECT is the gold standard for diagnosing SMVT with over 90% accuracy.
- Surgical resection is critical in cases of bowel infarction to prevent life-threatening complications.
- Lifelong anticoagulation is recommended for idiopathic SMVT to prevent recurrence.

## Abstract

Idiopathic superior mesenteric vein thrombosis (SMVT) is an uncommon but serious cause of mesenteric ischemia, accounting for 6–9 % of cases. Although SMVT is typically linked to hypercoagulable states, malignancy, or intra-abdominal inflammation, an idiopathic etiology persists in up to 25 % of cases even after exhaustive evaluation, underscoring diagnostic challenges and the need for vigilant workup.

A 46-year-old male presented with progressive abdominal pain, distension, and bilious vomiting. CECT identified SMVT with non-enhancing ileal loops, confirming gangrenous ileum. Emergency laparotomy revealed 100 cm of necrotic ileum, which was resected with ileostomy creation. Postoperative anticoagulation was initiated, and thrombophilia screening ruled out hypercoagulable disorders, classifying the SMVT as idiopathic.

SMVT presents insidiously with abdominal pain, vomiting, and distension; late features include peritonitis and hemodynamic instability. CECT remains the diagnostic gold standard with >90 % accuracy. Management algorithms stratify patients by stability and ischemia severity: stable patients may respond to anticoagulation alone, while those with infarction require prompt surgical resection and possible stoma formation. Lifelong or extended anticoagulation is advocated in idiopathic cases to prevent recurrence.

This case underscores that idiopathic SMVT, although rare and often diagnostically challenging, can rapidly progress to life-threatening bowel gangrene even in the absence of known risk factors. Timely diagnosis using contrast-enhanced CT and a multidisciplinary approach—including prompt surgical intervention and postoperative anticoagulation—are critical to improving survival and reducing long-term morbidity. This case reinforces the importance of maintaining a high index of suspicion and implementing early, coordinated management in suspected mesenteric ischemia.

•Idiopathic SMVT is a rare, life-threatening condition causing bowel ischemia, demanding high clinical suspicion for diagnosis.•CECT is the gold standard for diagnosing SMVT, revealing thrombus, bowel wall thickening, and signs of transmural infarction.•Conservative management with anticoagulation is effective in stable cases, while surgical resection is vital in infarction cases.•Prompt surgical intervention, including bowel resection and ileostomy, prevents complications from progressing bowel necrosis.•Lifelong anticoagulation may be necessary in idiopathic SMVT to reduce recurrence risk and avoid long-term thrombotic events.

Idiopathic SMVT is a rare, life-threatening condition causing bowel ischemia, demanding high clinical suspicion for diagnosis.

CECT is the gold standard for diagnosing SMVT, revealing thrombus, bowel wall thickening, and signs of transmural infarction.

Conservative management with anticoagulation is effective in stable cases, while surgical resection is vital in infarction cases.

Prompt surgical intervention, including bowel resection and ileostomy, prevents complications from progressing bowel necrosis.

Lifelong anticoagulation may be necessary in idiopathic SMVT to reduce recurrence risk and avoid long-term thrombotic events.