Shinshu Med J, 69⑶：141～147, 2021

Intestinal Obstruction Due to Mesenteric Inflammatory
Veno-occlusive Disease :A Case Report and Summary of the Literature
Hiroyuki Kobayashi1）2）, Satoru Joshita2）＊, Yuichi Nozawa1）
Tomoyuki Tanaka1）, Kenta Hashigami1）, Takanori Suganuma1）
Toshiharu Takahashi1）, Yoshiyuki Nakamura1）, Hiroaki Ogiwara3）
Kenji Sano4） and Takeji Umemura2）5）1） Department of Gastroenterology, Iida Municipal Hospital2） Department of Medicine, Division of Gastroenterology and Hepatology,
Shinshu University School of Medicine
3） Department of Gastroenterological Surgery, Iida Municipal Hospital4） Department of Pathology, Iida Municipal Hospital5） Department of Life Innovation, Institute for Biomedical Sciences, Shinshu University

Mesenteric inflammatory veno-occlusive disease (MIVOD) is an ischemic disorder caused by inflammationof the mesenteric veins without involvement of the arterial vessels. Lacking specific diagnostic findings, MIVOD
is difficult to confirm until surgical resection and histological analysis. We herein describe the clinical outcome ofan 82-year-old woman admitted to our hospital for abdominal pain, abdominal distention, and other symptoms
unresponsive to conservative medical treatment. No specific laboratory findings were noted apart from slightly
elevated C-reactive protein. Abdominal contrast-enhanced computed tomography (CT) revealed wall thickness
in the small intestine without abnormalities of the major trunk mesenteric vessels or free air in the abdominal
cavity. Conservative therapy with levofloxacin and streptomycin was given considering the possibility ofintestinal infection. The drugs were discontinued once her symptoms improved, but abdominal pain recurredalong with exacerbation of small intestinal niveau at 21 days of admission. A stenotic lesion on the anal side of
the small intestine detected in a gastrointestinal series was surgically resected. The excised tissue showedhistopathological evidence of ulceration and inflammation along with thrombus formation and luminal stenosis
and recanalization in the mesenteric vein, but not in arterial vessels, which confirmed the diagnosis of MIVOD.
She was later discharged with a favorable postoperative clinical course. Clinicians should bear in mind MIVOD
when encountering patients with unexplained abdominal pain or stenosis of the small intestine who are refractory
to conservative treatment. Shinshu Med J 69 : 141―147, 2021
(Received for publication January 8, 2021 ; accepted in revised form February 3, 2021)
Key words : mesenteric inflammatory veno-occlusive disease, ileus, small intestine,
thrombosis, mesenteric vein

Ⅰ

Introduction

Firstly reported as a phlebitis phenotype, mesen­＊

Corresponding author : Satoru Joshita
Department of Medicine, Division of Gastroenterology andHepatology, Shinshu University School of Medicine, 3-1-1
Asahi, Matsumoto, Nagano 390-8621, Japan
E-mail : joshita@shinshu-u.ac.jp

No. 3, 2021

teric inflammatory veno-occlusive disease (MIVOD)
is an ischemic disorder caused by inflammation oc­
curring exclusively in the mesenteric veins1）2）. Although
the etiology of MIVOD is unknown, the involvement
141

Kobayashi・Joshita・Nozawa et al.

of drug effects, cytomegalovirus infection, and anti­

Ⅱ Case Presentation

phospholipid syndrome has been reported1）3）-5）. MIVODrelated inflammation is histopathologically observed

An 82-year-old woman was initially admitted toin veins of all sizes, without arterial involvement,

our hospital for seven days for the treatment of ileus

along with such secondary changes as necrotizing

symptoms, which were relieved by ileus tube man­phlebitis, granulomatous phlebitis, and thrombus

agement. She had a history of surgery for gastric6）-8）

formation. However, it is difficult to diagnose theulcer perforation and conservatively treated ileus.

disease due to its rarity, lack of specific clinical find­

She was receiving medical treatment for hyper­ten­

9）

ings, and frequent confusion with other disorders .

sion, hyperuricemia, and osteoporosis. Six days

We herein describe the rare case of an elderly woman

after discharge from the first admission, she beganwith the clinical phenotype of intestinal obstruction

experiencing abdominal pain, abdominal distention,

who was diagnosed as having MIVOD, surgicallyand vomiting. Although her abdominal pain re­treated, and ultimately cured.

solved spontaneously, she visited a critical care center
Table 1

Laboratory data on admission

Blood test
White blood cells
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Red blood cells
Hemoglobin
Hematocrit
Platelet countChemistry/serology
3,700
68.5
23.7
5.4
1.9
0.5
407×104

/μL
％
％
％
％
％

/μL
12.4 g/dL
38.1 ％
31.8×104 /μL

Total protein
Albumin
AST
ALT
Total bilirubin
GGT

6.7 g/dL
3.2 g/dL
20 U/L
11 U/L
0.5 mg/dL
10 mg/dL

ALP
AmylaseBlood urea nitrogen

182
101
21.1

mg/dL
U/L
mg/dL

Creatinine
SodiumPotassium
Chlorine
C-reactive protein

0.76
139
4.3
105
0.83

mg/dL
mEq/L
mEq/L
mEq/L
mg/dL

Abbreviations : AST, aspartate aminotransferase ; ALT, alanine aminotransferase ; GGT,
gamma-glutamyl transpeptidase ; ALP, alkaline phosphataseFig. 1 Contrast-enhanced computed tomography (CT) in the early phase showed localized wall thickness (while
dotted circle) in the left upper abdominal small intestine (a). Chest CT revealed irregular nodules in the rightlower lung field (black arrowheads) (b) and small nodules in the right upper lung field (white arrow) (c).
142

Shinshu Med J

l. 69

Intestinal obstruction due to MIVOD

on the following day with the chief complaints ofpersistent abdominal distention and difficulty withfood intake. No remarkable findings were noted on
physical examination. Laboratory results were allwithin normal limits apart from slightly elevatedC-reactive protein (Table 1). Abdominal contrastenhanced computed tomography (CT) revealed
wall thickness in the small intestine localized at
the left upper abdomen (Fig. 1a), with no abnormal­
ities of the mesenteric vessels or free air in theabdominal cavity. Chest CT disclosed bronchial wall
thickness, small nodules in the lower right lung field,
and irregular nodules in the right upper lung field(Fig. 1b, c), which suggested the recurrence of small
intestinal obstruction and possible complicating tu­
berculosis in the lungs. Since intestinal tuberculosis
was also suspected as a cause of the obstruction,
repeated Pap smear and acid-fast bacteria testing of
the gastric fluid was performed, although the results
were negative. Mycobacterium intracellulare waslater detected by a smear test taken during bron­choscopy, and levofloxacin and streptomycin wereadministered considering the possibility of Mycobac-

Fig. 2 Gastrointestinal series by small intestinal endos­
copy detected a stenosis on the anal side of the small
intestine (white circle).

terium intracellulare-induced intestinal obstruction.
As normal bowel sounds were detected along withthe absence of abdominal tenderness, the drugs werediscontinued and she resumed oral food intake on
hospital day 13. However, intake was stopped fivedays later due to a recurrence of abdominal pain.
Additionally, small intestine niveau formation had
progressively worsened in sequential abdominal radio­
graphs during admission. Small intestine endoscopy
revealed no mucosal lesions or stenosis from theduodenal Vater papilla to the deepest insertion point,
although a gastrointestinal series detected stenosis

Fig. 3 Intraoperatively, 5 cm of inflammatory intestinal wall
thickness and stenosis were observed (black circle).

on the anal side of the small intestine (Fig. 2). We
performed surgical small intestinal resection on ad­

in the small intestinal wall and mesentery (Fig. 4a, b).

mission day 27. Inflammatory intestinal wall thickness

Thrombus formation and luminal stenosis and reca­

and a stenosis of 5 cm in length were observed 240

nalization were evident in the mesenteric vein along

cm distal to Treitz’s ligament and were adhered to thewith edema, congestion, and lymphocyte infiltration

surrounding small intestine and mesentery (Fig. 3).

(Fig. 4c). The arterial vessels remained intact (Fig.

The affected site was excised after ligating and cutting

4c). In the small intestinal mucosa, nonspecific in­

the mesentery. Histopathological examination of a tissue

flammatory findings mainly including lymphocytes

sample showed UL-IIIs ulceration and inflammationand plasma cells in the absence of a granuloma ex­

No. 3, 2021

143

Kobayashi・Joshita・Nozawa et al.

Fig. 4 An UL-IIIs ulceration was observed in the small
intestinal wall as a formalin-fixed macroscopic
finding (a). Inflammation of the small intestinal
wall and mesentery was observed in a magnified
image around the ulceration (hematoxylin andeosin staining) (b). Thrombosis and luminal stenosis
were detected in the mesenteric vein (arrows),
while the artery was intact (arrowheads) (c).

cluded the possibility of tuberculosis, Crohn’s disease,menced intravenous corticosteroid therapy since she

and ulcerative colitis while confirming the diagnosis

was initially diagnosed as having severe ulcerativeof MIVOD. She was discharged on day 41 with a fa­

colitis. However, she showed no improvement in clinicalvorable postoperative clinical course.

symptoms or laboratory findings. Afterward, sheⅢreceived colectomy and was finally diagnosed as

Discussion

having MIVOD with histological assessment13）. Thus,

Since the first described case of MIVOD in 19762）,

it is difficult to make a clear diagnosis of MIVOD

several terminologies, including MIVOD and entero­

before surgical treatment and a final histopathologicalcolic lymphocytic phlebitis, have been used to de­examination. Moreover, the duration between the

10）
11）

.

first onset of symptoms and clinical findings ranges

Due to its rarity, only 41 cases of MIVOD were re­from a day to months8）, but commonly lasts a week.

ported between 1980 and 2020 when searched by

As evidenced in this case, blood tests have little diag­

scribe the pathological findings of this entity

PubMed/MEDLINE, Embase on Ovid, and Ichushi-

nostic significance for MIVOD, although several reports

web, as summarized in Table 21）5）-9）12）-25）. Although ahave shown contrast-enhanced CT and angiography

relationship between MIVOD onset and drug effects,

as potentially helpful in identifying MIVOD12）13）. A

cytomegalovirus infection, and antiphospholipid syn­benefit of CT over histopathology is the ability to

1）
3）
-5）

, no report was found inevaluate both small pericolonic vessels and large

terms of involvement of Mycobacterium intracellulare

mesenteric veins12）. In our patient, however, contrast-

infection as detected in this case. The initial clinicalenhanced CT showed small intestine wall thickening,

symptoms of MIVOD are generally nonspecific andbut was unable to detect the mesenteric vein abnor­

include acute abdomen, nausea, abdominal pain, andmalities. The above observations support the idea

vomiting, all of which are also consistent with intestinalthat neither subjective symptoms nor objective find­perforation, strangulation ileus, and other abdominal

ings are specific for MIVOD in the absence of sur­disorders. Among reported cases, one case com­

gery and a careful differential diagnosis.

drome has been reported

144

Shinshu Med J

l. 69

Intestinal obstruction due to MIVOD
Table 2

Summary of MIVOD cases reported to dateCase Diagnosis

Age
Gender(years)

1)1）

MIVOD

29

Male

ND

Intestinal ischemia

Jejunum

10 days

2)5）

MIVOD

24

Male

Abdominal pain, purpuric skin lesionon the leg

Gangrene of small bowel

Ileum

2 days

3)6）

MIVOD

39

Male

Epigastric pain, nausea

Ischemic enteritis

Ileum

6 days

4)7）

MIVOD

78

FemaleAbdominal pain, nausea

Ischemic enteritis

Sigmoid colon

ND

5)7）

MIVOD

34

Male

Abdominal pain, nausea, vomiting

Ischemic enteritis

Jejunum

ND

6)7）

MIVOD

27

FemaleAbdominal pain, nausea, vomiting,bloody diarrhea

Ischemic enteritis

Jejunum

ND

7)7）

MIVOD

46

Male

Abdominal pain, nausea, vomiting,bloody diarrhea

Ischemic enteritis

Sigmoid colon

ND

8)7）

MIVOD

36

FemaleAbdominal pain

Ischemic enteritis

Right colon

ND

9)7）

MIVOD

60

FemaleAbdominal pain

Ischemic enteritis

Right colon

ND10)7） MIVOD

35

Male

Abdominal pain, rectal bleeding

Ischemic enteritis

Sigmoid colon

118） MIVOD

72

FemaleAcute abdomen

Intestinal perforation, strangulation ileus Jejunum128） MIVOD

75

FemaleAcute abdomen

Intestinal perforation, strangulation ileus Terminal ileum

6 days138） MIVOD

31

FemaleAcute abdomen

Appendicitis

Appendix

1 day148） MIVOD

68

Male

Acute abdomen

Intestinal perforation, strangulation ileus Jejunum

7 days158） MIVOD

53

Male

Acute abdomen

Intestinal perforation, strangulation ileus Ileum

3 days169） MIVOD

24

Male

Acute abdomen, nausea, vomiting,bloody diarrhea

Ischemic enteritis

Jejunum

ND179） MIVOD

65

FemaleIschemic enteritis

Ischemic enteritis

Jejunum

ND189） MIVOD

76

FemaleAcute abdomen, nausea, vomiting,bloody diarrhea

Ischemic enteritis

Jejunum

ND199） MIVOD

46

Male

Acute abdomen, nausea, vomiting,bloody diarrhea

Ischemic enteritis

Colon

ND

209） MIVOD

49

Male

Acute abdomen, nausea, vomiting,bloody diarrhea

Ischemic enteritis

Jejunum

ND219） MIVOD

59

Male

Acute abdomen, nausea, vomiting,bloody diarrhea

Ischemic enteritis

Jejunum

ND229） MIVOD

39

Male

Acute abdomen, nausea, vomiting,bloody diarrhea

Ischemic enteritis

Colon

ND

239） MIVOD

68

Male

Recurrent acalculous cholecystitis

Cholecystitis

Gallbladder

ND249） MIVOD

61

Male

Abdominal pain

Peritonitis

Omentum

ND259） MIVOD

42

Male

Acute abdomen, nausea, vomiting,bloody diarrhea

Ischemic bowel disease with perforation Jejunum and colonand peritonitis

ND2612） MIVOD

34

Male

Lower abdominal pain

Ulcerative colitis

Transverse colon andsigmoid colon

ND2712） MIVOD

65

Male

Abdominal pain

ND

From transverse
colon to rectumND2813） MIVOD

54

FemaleLeft lower abdominal pain

Inflammatory bowel disease

Sigmoid colon

ND2914） MIVOD

52

Male

Diarrhea, abdominal discomfort

Segmental colitis

Sigmoid colon

ND3015） ELP

65

Male

None

Gastric cancer

StomachND3116） ELP

78

Male

Acute abdomen

Strangulation ileus

Ileum

ND

3217） MIVOD

74

Male

Acute abdomenNon-occlusive mesenteric ischemia

Transverse colon

1 day3318） MIVOD

49

Male

Abdominal pain, fever

Ileus

Ascending colon

8months3419） ELP

26

Male

Abdominal pain

Upper gastrointestinal tract perforation

Ascending colon

8 days3519） ELP

32

FemaleNausea, abdominal pain

Strangulation ileus, inner inguinal hernia

Ileum

5 days3620） MIVOD

70

FemaleNausea, abdominal pain

Mesenteric venous thrombosis

Jejunum

1 month

3721)

MIVOD

32

Male

Severe diarrhea, epigastric pain

Perforation peritonitis

From transverse
colon to rectum

35 days3822） MIVOD

64

FemaleAcute epigastric pain

Intestinal ischemia

Ileum

ND

3923） MIVOD

65

Male

Proctalgia, rectal bleeding

Colonic ischemia

Sigmoid colon

30 days4024） MIVOD

32

Male

Bloody diarrhea, crampy left iliac
fossa pain

Pancolitis

Transverse colon anddescending colon

12 days4125） MIVOD

65

Male

Abdominal pain

Colonic stenosis and bowel obstruction

From descending
colon to rectum

57 daysThis MIVOD
case

82

FemaleAbdominal pain, ileus symptoms

Ileus

Ileum

6 daysClinical symptoms at onset

Diagnosis before surgery

Obstruction

Duration＊

ND
5 days＊: Duration between clinical symptom onset and exacerbation
Abbreviations : MIVOD, mesenteric inflammatory veno-occlusive disease ; ELP, enterocolic lymphocytic phlebitis ; ND, not described

No. 3, 2021

145

Kobayashi・Joshita・Nozawa et al.

No improvements in clinical symptoms were observ­

clinical findings prior to histologic identification fromed when we treated the patient conservatively for her

resected intestinal tract samples. Clinicians should

ileus symptoms. At that point, we established MIVOD

bear MIVOD in mind when encountering patientsas a differential diagnosis and proceeded to surgicalwith unexplained abdominal pain or stenosis of thetherapy. As evidenced by this case, the diagnosis ofsmall intestine and clinically unfavorable conservative

MIVOD can only be confirmed by the histologicaltreatment results. More cases are needed to clarify

examination of resected specimens, indicating thatthe clinical features, pathophysiology, and cause of

14）

surgery is needed for a definitive histological diagnosis .

MIVOD.

The characteristic histopathological features of MIVOD

Declarations

are lymphocytic, necrotizing, granulomatous, andEthics approval and consent to participate

mixed inflammatory infiltrates of mesenteric veins

Ethics committee approval was not required for thisand their intramural tributaries, with the secondarycase report.

development of thrombosis as a major and immediate

Consent for publication

cause of ischemic intestinal damage6）. Another important

Written informed consent was obtained from thehistopathological distinction is that the arterial vessels

patient for the publication of this report and all

remain intact and uninvolved. Although MIVOD seems

accompanying images.

to predominantly affect the colon, it has also been

Availability of data and material

reported in the small intestine, omentum, and gall

N/A

6）

bladder . The present case had a history of intestinal

Conflict of interest

obstruction, but its exact cause was unknown. Indeed,

The authors declare that they have no conflicts of

it is difficult to diagnose MIVOD at an early stage

interest.

due to its nonspecific symptoms and clinical findings ;Fundinga definitive diagnosis can only be made from histologi­

N/A

cal findings after surgical resection.

Acknowledgement
We greatly appreciate Drs. Akiyoshi Mochizuka,

Ⅳ Conclusion

Shinji Okaniwa, and Akihiro Tsukadaira for helping

We present a case of intestinal obstruction diagnosed

to see the patients as a team. The authors would likeas MIVOD following surgical treatment. MIVOD diag­

to thank Trevor Ralph for his English amendments

nosis is very difficult in light of the absence of specificto this report.

References
1） Ailani RK, Simms R, Caracioni AA, West BC : Extensive mesenteric inflammatory veno-occlusive disease of unknown
etiology after primary cytomegalovirus infection : first case. Am J Gastroenterol 92 : 1216-1218, 1997
2） Stevens SM, Gue S, Finckh ES : Necrotizing and giant cell granulomatous phlebitis of caecum and ascending colon.
Pathology 8 : 259-264, 1976
3） Saraga EP, Costa J : Idiopathic entero-colic lymphocytic phlebitis. A cause of ischemic intestinal necrosis. Am J Surg
Pathol 13 : 303-308, 1989
4） Pérez-Corral AM, Serrano D, Menarguez-Palanca J, et al : Mesenteric inflammatory veno-occlusive disease (MIVOD)
after allogeneic peripheral blood stem cell transplantation (PBSCT). Bone Marrow Transplant 41 : 311-313, 2008
5） Gül A, Inanç M, Ocal L, Koniçe M, Aral O, Lie JT : Primary antiphospholipid syndrome associated with mesentericinflammatory veno-occlusive disease. Clin Rheumatol 15 : 207-210, 1996
6） Eryigit E, Hoentjen F, Barbe E, van Meyel JJ : Intestinal ischaemia caused by mesenteric inflammatory venoocclusive disease. Neth J Med 66 : 486-488, 2008
7） Flaherty MJ, Lie JT, Haggitt RC : Mesenteric inflammatory veno-occlusive disease, A seldom recognized cause of146

Shinshu Med J

l. 69

Intestinal obstruction due to MIVOD
intestinal ischemia. Am J Surg Pathol 18 : 779-784, 1994
8） Hu JC, Forshaw MJ, Thebe P, Stewart M : Mesenteric inflammatory veno-occlusive disease as a cause of acuteabdomen : report of five cases. Surg Today 35 : 961-964, 2005
9） Lie JT : Mesenteric inflammatory veno-occlusive disease (MIVOD) : an emerging and unsuspected cause of digestive
tract ischemia. Vasa 26 : 91-96, 1997
10） Haber MM, Burrell M, West AB : Enterocolic lymphocytic phlebitis. Clinical, radiologic, and pathologic features. J
Clin Gastroenterol 17 : 327-332, 1993
11） Genta RM, Haggitt RC : Idiopathic myointimal hyperplasia of mesenteric veins. Gastroenterology 101 : 533-539, 199112） Miracle AC, Behr SC, Benhamida J, Gill RM, Yeh BC : Mesenteric inflammatory veno-occlusive disease : radiographic
and histopathologic evaluation of 2 cases. Abdom Imaging 39 : 18-24, 201413） Lavu K, Minocha A : Mesenteric inflammatory veno-occlusive disorder : a rare entity mimicking inflammatory bowel
disorder. Gastroenterology 125 : 236-239, 2003
14） Ayres LRO, Scott M, Shepherd N, Brown J : An unusual case of mesenteric ischaemia. Frontline Gastroenterol 5 :36-39, 201415） Hanada M, Kan K : Lymphocytic phlebitis of the stomach : a lesion morphologically equivalent to enterocolic lym­
phocytic phlebitis. J Toyonaka Muni Hosp 4 : 61-66, 2003
16） Ayata M, Hanada M : A case of enterocolic lymphocytic phlebitis in the small intestine. Journal of Toyonaka
Municipal Hospital 8 : 47-51, 2007 (in Japanese)17） Nakagawa N, Sakai M, Murai T, et al : A case of enterocolic lymphocytic phlebitis. J Jpn Surg Assoc 79 : 113-117,2018 (abstract available in English)18） Shirasaka K, Funahashi K, Koike J, et al : A Case of Mesenteric Inflammatory Veno-occlusive Disease (MIVOD) in a
Patient Presenting with Rapidly Progressing Symptoms of Intestinal Obstruction, with a Review of the Literature.
Journal of Japan Society of Coloproctology 66 : 95-100, 2013 (abstract available in English)19） Okada H, Sato M, Ozaki A, et al : Enterocolic Lymphocytic Phlebitis : a Report of Two Cases. Jpn J Gastroenterol
Surg 48 : 636-643, 2015 (abstract available in English)20） Taki C, Horinouchi M, Shimizu T, Kudama T, Tabata M, Sakoda K : A case of mesenteric inflammatory venoocclusive disease. Japanese Journal of Diagnostic Pathology 21 : 217-219, 2004 (in Japanese)21） Yamada Y, Sugimoto K, Yoshizawa Y, et al : Mesenteric inflammatory veno-occlusive disease occurring during thecourse of ulcerative colitis : a case report. BMC Gastroenterol 18 : 9, 201822） Tempia-Caliera AA, Renzulli P, Z’Graggen K, Lehmann T, Ruchti C, Buchler MW : Mesenteric inflammatory venoocclusive disease : a rare cause of intestinal ischemia. The first description of recurrent disease. Digestion 66 : 262264, 200223） Tuncer I, Colak Y, Yigitbasi R, et al : Mesenteric inflammatory veno-occlusive disease : an unusual cause of colonicischemia. Turk J Gastroenterol 22 : 561-562, 201124） Canavan JB, Coss A, Leader M, Patchett SE : Acute fulminant colitis caused by idiopathic mesenteric inflammatory
veno-occlusive disease. Case Rep Gastroenterol 1 : 152-156, 200725） Matsuda K, Hashiguchi Y, Kikuchi Y, et al : Successful surgical management of mesenteric inflammatory venoocclusive disease. Surg Case Rep 6 : 27, 2020（2021. 1. 8 received ; 2021. 2. 3 accepted）

No. 3, 2021

147