Guideline sources The following summarized guidelines for the evaluation and management of mesenteric vein thrombosis (MVT) are prepared by our editorial team based on guidelines from the American Society of Hematology (ASH 2023), the World Society of Emergency Surgery (WSES 2022), the American Association for the Study of Liver Diseases (AASLD 2021), the American College of Gastroenterology (ACG 2020), the American Gastroenterological Association (AGA 2018), the European Society for Vascular Surgery (ESVS 2017), the European Association for the Study of the Liver (EASL 2016), and the European Society for Trauma and Emergency Surgery (ESTES 2016). 1 2 3 4 5 6 7 8 Guidelines 1. Diagnostic investigations Indications for testing (portal vein thrombosis): obtain contrast-enhanced CT or MRI to assess the extension of thrombus into the mesenteric veins and to exclude tumor thrombus in patients with cirrhosis developing new portal and/or mesenteric vein thrombus. B Indications for testing (portal hypertension): suspect MVT as one of the possible diagnoses in patients with newly diagnosed portal hypertension. B Indications for testing (Crohn's disease): assess for evidence of mesenteric vein thromboses during CT enterography and MR enterography in patients with Crohn's disease. A Computed tomography angiography: https://web.pathway.md/diseases/recJ6TJpLVZAnqDs9 1/4 6/30/23, 1:01 AM Mesenteric vein thrombosis Pathway Computed tomography angiography: Obtain CT angiography with arterial and portal phases in patients with suspected MVT. B Rule out the possibility of intestinal infarction until the resolution of pain in patients with MVT. B Evaluation for etiology: As per ESVS 2017 guidelines, evaluate for abdominal cancer, inflammatory disease, and myeloproliferative neoplasms in patients with MVT. B Show 2 more As per ESTES 2016 guidelines, evaluate for thrombophilia in patients with MVT. B 2. Medical management Anticoagulation therapy, indications: As per WSES 2022 guidelines, consider administering a continuous infusion of UFH for the management of patients with mesenteric venous thrombosis. B As per AASLD 2021 guidelines, consider initiating antithrombotic therapy in patients with cirrhosis with recent occlusive or partially occlusive (> 50% obstruction of the lumen) thrombosis of the main portal vein or mesenteric veins, in order to avoid thrombosis progression possibly hindering future liver transplantation or causing progression of portal hypertension. E As per ACG 2020 guidelines, initiate anticoagulation in all symptomatic patients with non- cirrhotic, acute MVT in the absence of contraindications. B Show 6 more As per ESVS 2017 guidelines, administer heparin as first-line therapy in patients with acute MVT without peritonitis. B Anticoagulation therapy, duration: As per ASH 2023 guidelines: Consider obtaining thrombophilia testing to guide anticoagulant treatment duration after primary treatment in patients with splanchnic venous thrombosis in a setting where anticoagulation would be discontinued. Consider continuing anticoagulation indefinitely in patients with thrombophilia. C Avoid obtaining thrombophilia testing to guide anticoagulant treatment duration after primary treatment in patients with splanchnic venous thrombosis in a setting where anticoagulation would be continued indefinitely. D As per ACG 2020 guidelines: Consider continuing anticoagulation for at least 6 months in patients with non-cirrhotic MVT without thrombophilia and when the etiology of the thrombosis is reversible. Continue anticoagulation indefinitely in patients with non-cirrhotic MVT with thrombophilia. C Consider continuing anticoagulation for 6 months in patients with cirrhotic MVT. Continue anticoagulation beyond this period in patients with cirrhotic MVT awaiting a liver transplant. C As per ESVS 2017 guidelines: https://web.pathway.md/diseases/recJ6TJpLVZAnqDs9 2/4 6/30/23, 1:01 AM Mesenteric vein thrombosis Pathway Continue anticoagulation for 3-6 months in patients with MVT with reversible causes (such as trauma, infection, or pancreatitis). B Continue anticoagulation lifelong in patients with MVT with any of the following: proven thrombophilia recurrent venous thrombosis progression or recurrence of thrombosis would have severe clinical consequences. B As per EASL 2016 guidelines, consider continuing anticoagulation lifelong in patients with superior mesenteric venous thrombosis with a past history suggestive of intestinal ischemia or being liver transplant candidates. C As per ESTES 2016 guidelines, continue anticoagulation therapy, when indicated, for a minimum of 6 months in patients with MVT. B Prevention of variceal bleeding: Initiate nonselective -blockers for the prevention of variceal bleeding in patients with high-risk varices and portal and/or mesenteric venous thrombosis requiring anticoagulation. B Consider performing endoscopic variceal ligation if there are contraindications or intolerance to -blockers. Consider interrupting anticoagulation in the periprocedural period. B Clinical findings Symptoms Past medical history Abdominal pain Acute mesenteric ischemia Nausea Acute pancreatitis Vomiting Antiphospholipid syndrome Antithrombin III deficiency Medication history FVL mutation IBD Hormonal contraceptives Malignancy Abdominal exam Myeloproliferative disease Nephrotic syndrome Abdominal distension Portal hypertension Abdominal tenderness Portal vein thrombosis Peritoneal findings Protein C deficiency Rebound tenderness Protein S deficiency bowel sounds Prothrombin G20210A mutation Thrombophilia Imaging findings Past surgical history Bowel wall thickening Distended bowel loops Bariatric surgery Splenectomy https://web.pathway.md/diseases/recJ6TJpLVZAnqDs9 3/4 6/30/23, 1:01 AM Mesenteric vein thrombosis Pathway Lab findings References 1. M Bj rck, M Koelemay, S Acosta et al. Editor's Choice Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery ESVS . Eur J Vasc Endovasc Surg. 2017 Apr;53 4 460 510. Open 2. Saskia Middeldorp, Robby Nieuwlaat, Lisa Baumann Kreuziger et al. American Society of Hematology 2023 Guidelines for Management of Venous Thromboembolism: Thrombophilia Testing. Blood Adv. 2023 May 17;bloodadvances.2023010177. Open 3. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Vascular diseases of the liver. J Hepatol. 2016 Jan;64 1 179 202. Open 4. Douglas A Simonetto, Ashwani K Singal, Guadalupe Garcia-Tsao et al. ACG Clinical Guideline: Disorders of the Hepatic and Mesenteric Circulation. Am J Gastroenterol. 2020 Jan;115 1 18 40. Open 5. Bruining DH, Zimmermann EM, Loftus EV Jr et al. Consensus Recommendations for Evaluation, Interpretation, and Utilization of Computed Tomography and Magnetic Resonance Enterography in Patients With Small Bowel Crohn's Disease. Radiology. 2018 Mar;286 3 776 799. Open 6. Miklosh Bala, Fausto Catena, Jeffry Kashuk et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. WSES. 2022 Oct;. Open 7. Tilsed JV, Casamassima A, Kurihara H et al. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg. 2016 Apr;42 2 253 70. Open 8. Patrick G Northup, Juan Carlos Garcia-Pagan, Guadalupe Garcia-Tsao et al. Vascular Liver Disorders, Portal Vein Thrombosis, and Procedural Bleeding in Patients With Liver Disease: 2020 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Jan;73 1 366 413. Open 9. Campbell Tait, Trevor Baglin, Henry Watson et al. Guidelines on the investigation and management of venous thrombosis at unusual sites. Br J Haematol. 2012 Oct;159 1 28 38. Open https://web.pathway.md/diseases/recJ6TJpLVZAnqDs9 4/4