Recently, Department of Interventional Medicine of the Second Hospital of Shandong University successfully treated a patient afflicted with small intestine necrosis, mesenteric venous thrombosis, portal vein thrombosis, and upper gastrointestinal bleeding. This achievement was the result of collaborative efforts with departments including Department of Gastrointestinal Surgery, Department of Anesthesiology II, Intensive Care Unit, and Department of Gastroenterology.

Ms. Zhao, a 45-year-old female, was urgently transported to the Emergency Department of the Second Hospital of Shandong University via a 120 ambulance due to two days of abdominal pain that had intensified over the last day. With a medical history spanning over two decades, she had battled hepatitis B cirrhosis and had undergone a splenectomy four years prior following an episode of hematemesis.

Upon admission, a battery of urgent examinations was swiftly initiated. Enhanced CT imaging of the upper abdomen uncovered hepatic cirrhosis, portal hypertension, ascites, and notable intra-abdominal exudate, in addition to portal and mesenteric venous thrombosis. Physical assessment revealed abdominal distension, diffuse tenderness, rebound tenderness, and hypoactive bowel sounds. In light of these findings, an urgent multidisciplinary consultation was convened, engaging experts from Department of Gastrointestinal Surgery and Intensive Care Unit. The consensus was a diagnosis of small intestine necrosis compounded by severe intra-abdominal infection. Emergent exploratory laparotomy was skillfully executed under the lead of Dr. Wang Peilin,Chief Surgeon, Department of Gastrointestinal Surgery,Within the surgical field, a copious volume of opaque fluid was encountered within the abdominal cavity, accompanied by the grim discovery of approximately 50cm of necrotic small intestine.

The patient's post-operative recovery was marked by positive progress. By the third day after the procedure, she had transitioned from the Intensive Care Unit to the Department of Gastrointestinal Surgery. However, on the seventh day following the operation, an unforeseen episode of hematemesis occurred. Given the patient's history of hepatic cirrhosis, the foremost concern was esophagogastric variceal bleeding. Despite efforts with conservative treatment, the results were suboptimal, and her hemoglobin levels steadily declined, ultimately reaching a nadir of 62g/L. A comprehensive multidisciplinary consultationwas convened, engaging specialists from Department of Gastrointestinal Surgery, Department of Interventional Medicine, Department of Gastroenterology, Department of Hepatology, Department of Hematology, Department of Vascular Surgery, and Intensive Care Unit. Following a meticulous discussion, it was determined that an emergency Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure would be performed to address the bleeding by Department of Interventional Medicine. Subsequently, the patient would receive comprehensive post-operative care within the Intensive Care Unit.

Due to the patient's prior splenectomy and the presence of a thrombus in the main portal vein, portal vein puncture during TIPS presented considerable technical challenges. The Department of Interventional Medicine team conducted a thorough preoperative analysis and, guided by the enhanced CT scan, devised an intricate procedural plan along with a comprehensive risk management strategy. The procedure was skillfully overseen by Dr. Li Yuliang, Chief of Department of Interventional Medicine. Throughout the operation, a series of technical hurdles, including the s thinning main portal vein and intricate opening of varicose vein branches, were adeptly navigated. This resulted not only in the successful embolization of the ruptured vessels but also in the establishment of a functional shunt. Following the procedure, the patient was promptly transferred to the Intensive Care Unit for further specialized care. There were no subsequent episodes of hematemesis, and the melena gradually subsided. The resumption of oral intake was a positive sign, and there were no indications of hepatic encephalopathy. The patient has now made a complete recovery and has been discharged.

Acute thrombosis in the mesenteric venous system and portal vein poses a highly perilous situation. Delayed diagnosis and treatment may lead to extensive small intestine necrosis, carrying an exceedingly high mortality rate. Esophagogastric variceal bleeding in the context of hepatic cirrhosis is the gravest complication, with initial hemorrhage mortality rates reported in the literature ranging from 15% to 25%, and a heightened risk of rebleeding. Transjugular Intrahepatic Portosystemic Shunt (TIPS), which establishes a shunt between the hepatic vein and portal vein, fundamentally reduces portal vein pressure and stands as the most effective surgical approach for managing bleeding. Post-TIPS hepatic encephalopathy is often linked to inappropriate postoperative dietary choices. With proper dietary management, the majority of patients can steer clear of this complication. While it's a widely held belief that patients with portal vein thrombosis are unsuitable candidates for TIPS, recent practices in the Department of Interventional Medicine team demonstrate that, with meticulous preparation and collaborative efforts, what were once viewed as contraindications can be transformed into valid indications.

The successful treatment of this patient exemplifies the proficiency of Shandong University Second Hospital in handling complex, severe and critical cases, and fatal cases. It underscores the benefits of MDT diagnosis and treatment, showcasing the hospital's collaborative strengths.