Use of Rivaroxaban for Mesenteric Vein Thrombosis Secondary to Diverticulitis: A Case Report

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To the Editor:
Pylephlebitis or thrombophlebitis in portal veins and mesenteric veins may arise as an uncommon complication of intra-abdominal inflammatory process like diverticulitis.1 We report what we believe is a rare case of thrombophlebitis of the inferior mesenteric vein after resolution of diverticulitis for which rivaroxaban was used.
A 72-year-old woman with a history of diabetes and hypertension presented with left lower quadrant pain and fever for 7 days. Computed tomography of the abdomen and pelvis showed thromboses of the inferior mesenteric vein extending from the proximal sigmoid colon to superior mesenteric vein and colonic diverticulosis without diverticulitis (Figure 1). Lower extremity venous Doppler was negative for deep venous thrombosis. Blood cultures, tumor markers such as CEA, CA 19-9, AFP, and lupus anticoagulant antibodies were negative. She had no risk factor usually associated with pylephlebitis. It is likely that she developed diverticulitis that led to mesenteric vein thrombophlebitis. A heparin drip along with ciprofloxacin 500 mg iv twice daily and Flagyl 500 mg iv every 8 hours was started. After 24 hours, her abdominal pain was reduced and diet was advanced as tolerated. Coumadin bridging was started, but the patient did not want to stay for titration. Hence, rivaroxaban was started for oral anticoagulation and heparin was discontinued. On the fifth day of hospital stay, the patient was discharged. Computed tomography with contrast was repeated after 2 months and showed improvement with collaterals.
Rivaroxaban is a factor X inhibitor indicated for the treatment of nonvalvular atrial fibrillation, venous thromboembolism and its prophylaxis after various surgeries. It is not a proven indication for pylephlebitis but was successful for our patient both in symptom relief and compliance. Studies show that the cost of rivaroxaban, being more than warfarin, is compensated by the cost of monitoring, hospital stay, and health care provider's time required for managing test results.2 Use in pylephlebitis due to liver cirrhosis has been discouraged because of increased risk of variceal bleeding and liver injury.3 However, patients with thrombosis in mesenteric veins due to inflammatory bowel disease especially in resolution have lower risk of bleeding or liver toxicity. These patients can benefit from nontraditional anticoagulation. In addition, the concern for breakthrough bleeding can be alleviated by promising agents like andexanet alfa that may be approved soon.4 We recommend use of these agents to be considered especially in cases like our patient.

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