Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

Introduction Inferior vena cava (IVC) thrombosis is an under-recognized entity that is associated with significant morbidity and mortality. IVC thrombosis is prevalent (60% to 80%) among patients with congenital IVC anomalies. These anomalies occur in 0.5%–1% of the general population. Thrombosis of the IVC in the absence of congenital abnormalities is rare and is usually a result of a predisposing hypercoagulable state or IVC filter. Here, we present a case of an incidental finding of IVC thrombosis in a patient presenting with gastroenteritis. Case description A 57-year-old female with a past medical history of obstructive sleep apnea, and non-alcoholic steatohepatitis (NASH) presented with a five-day history of generalized abdominal pain, vomiting, and diarrhea. The laboratory tests fecal calprotectin of 196. The patient denied prior thromboembolic events, recent trauma or surgery, malignancy, contraceptive use, past or current smoking. A CT scan of the abdomen with IV contrast was obtained and showed circumferential thickening of the descending colon, a partially calcified thrombus predominantly within the infrahepatic and suprarenal IVC with extension into the hepatic portion, and a left renal vein that obstructed 40% of the IVC lumen. The patient was initially diagnosed with viral gastroenteritis and IVC thrombosis and was put on supportive treatment and IV heparin infusion. Further evaluation with bilateral lower extremity and IVC/iliac vein Doppler ultrasonography was unremarkable. Chart review of the patient’s medical records showed that the patient was up to date with her age-appropriate cancer screenings, including a colonoscopy one year ago, which was unremarkable. Thrombophilia workup, including JAK 2 gene mutation and paroxysmal nocturnal hemoglobinuria (PNH) screens, was remarkable for decreased antithrombin and increased Factor VIII activity. The patient’s symptoms resolved with supportive treatment, and the patient was discharged on apixaban for outpatient follow-up. Discussion IVC thrombosis is a challenging diagnosis for most physicians. It usually has an insidious onset, and the clinical presentation is often ambiguous with nonspecific symptoms. Additionally, physicians are often not familiar with IVC thrombosis and may not entertain this diagnosis unless the patient has a proximal lower extremity DVT. In our case, IVC thrombosis was an incidental and unexpected finding. The thrombophilia workup showed decreased antithrombin levels and increased Factor VIII activity levels. Factor VIII is a known acute-phase reactant, and in an acute inflammatory state, which is shown by the elevated calprotectin level in our patient, it is not reliable. Antithrombin deficiency is rare, with a prevalence of approximately 0.02% in the general population and false-positive results may be seen with liver disease and heparin therapy. There are no specific societal guidelines currently available to aid with the diagnosis and management of IVC thrombosis. Further research and studies are required to define precise guidelines for IVC thrombosis, especially considering the rising use of IVC filters along with elevated late thrombosis rates in up to 33% of patients.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter 2025 Resident and Medical Student Day, May 2, 2025, Troy, MI

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