Kiran

A. Jam,

MD

#{149} R.

Brooke

Jeffrey,

Jr, MD

Gonadal Vein Thrombosis with Acute Gastrointestinal Inflammation: Diagnosis During a 31-month period, evidence of gonadal vein thrombosis (GVT) was demonstrated by computed tomography (CT) in seven patients who had a broad spectrum of acute gastrointestinal inflammatory lesions, including diverticulitis, ulcerative colitis, Crohn disease, appendicitis with abscess, and perforated appendix with pseudomembranous

colitis. All patients had lower abdominal pain, tenderness, fever, and leukocytosis. CT demonstrated thrombus through the length of the gonadal vein in each patient; the entire lumen of the vein was filled. No symptoms relating to GVT were present. GVT may resolve with treatment of the underlying enteric disease alone, and anticoagulant therapy may not be necessary. Index 75.263

terms: Colitis, pseudomembranous, #{149} Colitis, ulcerative, 75.261 #{149}Colon, diverticula, 75.27 #{149}Gastrointestinal tract, inflam-

mation, Thrombosis, Radiology

70.20

Intestines,

#{149}

venous, 1991;

diseases,

75.262

G

In Patients with

vein thrombosis (GVT) associated with dis-

ONADAL

typically seminated

CT’

ovarian

carcinoma,

ovarian

vein

(CT),

magnetic

has

resonance

(7-10).

Using

nosed

GVT

a variety flammatory

CT,

we

in seven

and

is

diag-

patients

who

of acute gastrointestinal disorders. These

to

AND

April

examined

seven

patients

tinat inflammation

patients

trointestinal ders. There

CT disclosed patients also of acute gas-

inflammatory were five men

bowel disorand two wom-

en, with an age range of 30-58 years. The CT studies and medical records of each of the seven patients were reviewed

retrospectively. performed

All CT examinations with

contrast

tered orally (40 mL mixed Gastroview, Mallinckrodt Louis) and intravenously

paque mine

meglumine injection

ceuticabs, (model

pelvis.

The

sion received March dress reprint requests 0 RSNA, 1991

sis was

made

ria, including bosed vein,

meglu-

Pharma-

York) on a CT scanner

waukee). Consecutive were obtained through

13. Ad-

with water; MD Medical, St (150 mL of Hy-

Winthrop

GE Medical

From the Department of Diagnostic Radiology, Rm H-1307, Stanford University School of Medicine, Stanford, CA 94305. Received January 23, 1991; revision requested February 18; reviMarch

adminis-

60%, diatrizoate USP;

New 9800;

were

medium

diagnosis on

the

Systems,

Md-

10-mm-thick the abdomen of venous basis

enlargement a bow-attenuation

of prior

of

had

developed

colitis.

a ruptured

appendix

One patient with

abscess

for-

in two

patient.

RESULTS Thrombosis was noted in the left gonadal vein (Fig 1) in five patients, of whom four were male and one was female (Table). Thrombosis was noted in the right gonadal vein in the remaining two patients, of whom one was male and the other was female. patient

with

ruptured

appendix

had thrombus of the left gonadab vein with gas formation secondary to sep-

gastrointes-

in whom

evidence of GVT. All seven had clinical and CT evidence

diverticulitis,

exacerbation

had

1990, we

with

and

in-

METHODS

1988 to October

acute

and sigmoid colon were patients, the ascending colon was involved in two patients, the transverse colon was involved in two patients, and the entire colon was involved

One

From

11; accepted to K.A.J.

had

in one

had clinical and CT evidence of acute enteric inflammation, and GVT was incidentally discovered. In this report, we will analyze the clinical significance of GVT in this setting, as well as patterns of resolution.

MATERIALS

had acute

had

peritonitis

involved

969.751

180:111-113

enhancing

mation (Table). The descending

proved of GVT

recently

patients

patient

pseudomembranous

imag-

ing, and sonography have be helpful in the detection

defined

Crohn disease, and one patient had acute exacerbation of ulcerative colitis. One patient was treated for ruptured appendix

Re-

thrombosis

and a sharply (7-10).

Three one

also been reported in patients with malignant tumors other than ovarian carcinoma (4). GVT in male patients uncommon, although there have been case reports of spermatic vein thrombosis (5,6). Computed tomography

lumen, wall

puer-

peral infections, and gynecobogic surgery in female patients (1-3). cently,

is

scans and

sis (Fig 2). In the gonadal

veins,

strated thrombus level of the renal

extending from the vein to the pelvic

brim.

In all patients,

CT demon-

the

thrombus

was seen in all CT sections for the entire length of the gonadal vein and the entire lumen was filled with thrombus. No portion of the gonadal vein was opacified with contrast medium. No patient had localizing ,

symptoms

was

attributable

no evidence

to GVT.

of pelvic

There

tumor

or

any abdominal malignancy on the CT scans. None of the patients had underlying coagulopathy. Blood cub-

tures were obtained in two with appendicitis and were for pyogenic infections.

patients positive

thromboCT

crite-

of the thromcentral

Abbreviation: sis.

GVT

=

gonadal

vein

thrombo-

111

CT studies of the abdomen or pelvis obtained before the initial detection of GVT were available for two of the

volved

than

lished

incidence

seven

ies

patients.

CT

scans

were

ob-

tamed 6 and 8 months, respectively, before the examination described here. There was no evidence of GVT on these prior CT scans (Fig 3). After detection of GVT in these patients, their inflammation was treated with antibiotics. However, no patient was given anticoagulants. The decision was

not to use anticoagulant based on the combination

therapy of fac-

tors that none of the patients had underlying coagulopathy and none had localizing symptoms attributable to GVT. Also, the unknown duration of the GVT at the time of detection dissuaded the clinicians from prescribing anticoagulants. No

complications

embolism) thrombosis

tients. tal

(ie,

or extension occurred

There

was

or inguinal

pulmonary

to deep in any

no evidence

swelling.

vein

of the

was

left

is one

Spontaneous

thrombosis

scrotal Roach

in the

No

available

follow-up

for the

CT

remaining

scans

were

three

pa-

tients.

DISCUSSION

reported throm-

by spermatic reported

initiation

of gonadal

vein

by vein

by

of GVT.

thrombus

yielded

anaerobic

species,

staphylococci, and

yeast

are multiple

incompetent

the

vein

gonadal

Cultures

have

that

valves

in

act

as a site

may

for stasis or a nidus for thrombosis (7), although it is not clear why the gonadal vein was exclusively involved in our patients. However, isolated thrombosis

been cancer

was

of the

gonadab

documented (4). None

evident

vein

in patients of our

on

patients

bowel previously Although CT

has

with

scans,

with

disease necogthe GVT no

(7,10) Thus

or inguinoscrotal the cause and

GVT

in our

similar

patient

seven

to those

swelling manifestations

patients

dis-

described.

tum endometritis vic inflammatory

of the bilateral

likely the result of ascending septic thrombophbebitis (1,11). The right ovarian vein is more commonly in-

112

#{149} Radiology

uneters (15,16). Asymptomatic ovarian infarction and

ian venous reported

boembolism

thrombosis (17).

Pulmonary

has

been

have

also

ovar-

been

throm-

reported

CT scan

(arrow).

of a patient

with

a nip-

shows low attenuation gas in the left gonadal

The gonadal

an inflammatory

mass

vein

vein

is surrounded

by

(arrowheads).

of

were

previously

2.

tured appendix thrombus and

(5).

The recognized complications of ovarian vein thrombosis are septic pulmonary embolism and obstruction

peb-

Figure

had symptoms rebating to GVT or had CT findings of an enlarged uterus

GVT occurs in limited clinical situations. Ovarian vein thrombosis is a well-known complication of postparin patients with disease. This is

gonadal vein (arrow). The vein is enlarged, the central lumen is of low attenuation because of the presence of thrombus, and the vessel wall is enhanced after the intravenous administration of contrast medium. Notice the thickened wall of the ascending colon (Ac).

streptococci, Proteus Bacteroides speorganisms (2). There

acute inflammatory belonged to the nized risk group.

tients.

vein

inguino-

Delevett and Goodrich (6). Banner’s review of the literature on genitourinany complications of inflammatory bowel disease (14) does not cite GVT. In our seven patients, the left gonadal vein was involved more frequently than the right irrespective of the site of inflammation. The plausible pathogenesis seems to be bacterial insult to the endothelium from the pelvic inflammatory process (1). Bacterial injury to the endothehum is believed to be the essential

by 3 months (Fig 3). However, sisted for more than 3 months

no follow-up was 3 months in these pa-

acute

caused has been

cies,

other patients; available after

pubovarian

in 600 deliver-

swelling has been et al (5). Pulmonary

boembolism thrombosis

The

spermatic

causing

performed on the two patients with ruptured appendix. In one of these patients the preoperative CT scan showed GVT (Fig 2). The other patient with ruptured appendix and peritonitis underwent postoperative CT when he developed pseudomembranous colitis from antibiotic treatment; GVT was detected on this scan. GVT had resolved in two patients it perin two

(2,12).

of puenpenal

thrombosis (13).

step

pa-

of scro-

Surgery

vein

the

from

thrombophlebitis

of the

vein (6), and spontaneous of the spenmatic vein can venous chemia

congestion that requires

Prompt treatment and anticoagubants

spenmatic

thrombosis cause

and testicular orchiectomy

is(5).

with antibiotics is usually mdi-

cated (1,5,1 1). Spontaneous of ovarian vein thrombosis anticoagulation therapy

resolution without was docu-

July

1991

b. Figure months tamed changes

olution

mented studied

in two of the five patients by Jacoby et al (4). Surgical intervention is reserved for patients in whom medical treatment fails (1,2). The death rate associated with ovarian vein thrombosis has been estimated to be 18 per 1 million pregnancies

C.

3. Resolution of left ovarian vein thrombosis in a patient with acute diverticulitis of the transverse colon. (a) Initial CT scan obtained before the episode of acute diverticulitis shows well-opacified left gonadal vein (arrow) with no evidence of thrombus. (b) CT scan during the acute symptoms of diverticulitis shows extensive thickening of the transverse colon (Tc) with surrounding inflammatory (arrowheads). Thrombus is seen in the enlarged left gonadal vein (arrow). (c) Follow-up CT scan obtained 10 weeks after b shows of inflammatory changes in the transverse colon (Tc), as well as resolution of thrombus in the left gonadal vein (arrow).

(18).

In our

small

group,

2.

3.

4.

5.

6.

7.

8.

9. Duff P, Gibbs RS. Pelvic vein thrombophiebitis: diagnostic dilemma and therapeutic challenges. Obstet Gynecol Surg 1983; 38:365-373.

Volume

180

#{149} Number

1

LA.

of puerperal

thrombophlebitis. 1981; 36:57-66. Hughey M, McElin surgical diagnosis

Obstet

A review

ovarian Gynecol

of

10.

11.

vein

ThY, Caprini and management

JA.

Josey WE, Staggers in septic

of46

Surg Nonof pu-

erperal ovarian vein thrombophiebitis. J Obstet Gynecol 1979; 133:461-463.

References 1.

RA, Gillanders

the syndrome

no

complications of GVT occurred. With the increasing use of crosssectional imaging techniques, it is likely that GVT will be diagnosed more frequently. Beller et al (19) reported incidental detection of ovarian vein thrombosis at cesarean section. The need for routine anticoagulant therapy in addition to antibiotics in these patients is not yet clear, because it has been documented by Jacoby et al (4) that thrombus can resolve without complications even in the absence of treatment. U

Munsick

Am

12.

SR.

228-233. Reynolds

SR.

Obstet

Heparin

Right

a study

Gynecol

ovarian

Gynecol

res-

therapy

thrombophlebitis:

cases. Am J Obstet

drome.

1974; 120:

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syn-

1971; 37:308-313.

15.

Ruhmland B, Reiher H, Randao H. A case of septic ovarian vein thrombosis. Zentralbl-Gynaekol 1990; 112:383-386. Banner MP. Genitourinary complications of inflammatory bowel disease. Radiol Clin North Am 1987; 25:199-209. Josey WE, Cook CC. Septic vein throm-

bitis ofleft spermatic vein and pulmonary thromboembolism: cure by ligation. Johns Hopkins Med J 1970; 126:15-18. Savader SJ, Otero PR, Savader BL. Puerperal ovarian vein thrombosis: evaluation with CT, US, and MR imaging. Radiology 1988; 167:637-639. Warhit JM, Fagelman D, Goldman MA, Weiss LM, Sachs L. Ovarian vein thrombophlebitis: diagnosis by ultrasound and CT. JCU 1984; 12:301-303.

16.

bophlebitis: report of 17 patients treated with heparin. Obstet Gynecol 1970; 35:891896. Schapiro HE, Mitty HA. Right ovarian

17.

vein thrombophlebitis causing ureteral obstruction. J Urol 1974; 112:451-453. Gardstein HF Jr, Ferenczy A, Richart RM.

RozierJC,

19.

Jacoby WT, Cohan RH, Baker ME, Leder RA, Nadel SN, Dunnick NR. Ovarian vein thrombosis in oncology patients: CT detection. AJR 1990; 155:291-294. Roach R, Messing E, StarlingJ. Spontaneous thrombosis of left spermatic vein: re-

13.

pelvic

6 ob-

14.

port of 2 cases. J Urol 1985; 134:369-370. Delevett AF, Goodrich A. Thrombophle-

Brown

EH, Berne

FA.

Diagno-

sis of puerperal ovarian vein thrombophlebitis by computed tomography. Am J Obstet Gynecol 1988; 159:737-740. Khurana BK, Rao J, Friedman SA, Cho KC. Computed tomographic features of puer-

peral ovarian vein thrombosis. Gynecol 1988; 159:905-908.

Asymptomatic bilateral ovarian infarction and venous thrombosis. Am J Obstet Gynecol 1973; 116:1164-1166. 18.

Derrick

Evidence

FC, Rosenblum

of right

in pregnant 35:37-39.

RR, Lynch

ovarian

females.

KM.

vein syndrome

Obstet

Gynecol

1970;

BelIer FK, Quakernack K, Within G. Incidental detection of ovarian vein thrombosis along

Gynaekol

with

caesarean

section.

Zentralbl-

1980; 102:1059-1062.

Am J Obstet

Radiology

#{149} 113