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Thrombosed Pelvic Collateral Veins Resulting from Anomalous Inferior Vena Cava: A Mimicker of Acute Appendicitis

¹ University Health Network and Mount Sinai Hospital University of Toronto Toronto, ON M5G 2N2, Canada

A 22-year-old man with a history of congenital heart disease presented with right lower quadrant pain and tenderness. Sonography showed a noncompressible, tubular, predominantly hypoechoic structure at the region of maximal tenderness. A trace of free fluid and echogenic inflammatory fat was seen surrounding this structure (Figs. 2A and 2B). No Doppler flow was detected in this structure on sonography.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —22-year-old man with infrarenal absence of inferior vena cava and thrombosis of right pelvic collateral vein mimicking acute appendicitis. Sagittal (A) and transverse (B) sonograms show distended, noncompressible tubular structure (arrow) in right lower quadrant. Note adjacent inflammatory echogenic fat and small amount of free fluid.

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —22-year-old man with infrarenal absence of inferior vena cava and thrombosis of right pelvic collateral vein mimicking acute appendicitis. Sagittal (A) and transverse (B) sonograms show distended, noncompressible tubular structure (arrow) in right lower quadrant. Note adjacent inflammatory echogenic fat and small amount of free fluid.

The diagnosis of acute appendicitis was considered, although two features were not entirely in keeping with this. First, a communication between the tubular structure and the cecum could not be visualized. Second, a definite blind end could not be identified. We thought that if the appendix had ruptured, then such features might be absent.

Because the sonographic diagnosis was uncertain, MDCT was performed. The patient refused IV contrast material. MDCT revealed a distended, hyperdense right pelvic collateral vein with surrounding fat stranding and free fluid (Fig. 2C). The inferior vena cava was anomalous, with normal preservation of the suprarenal portion but absence of the infrarenal portion (Fig. 2D). In addition, both common iliac veins were absent. On the left, the external and internal iliac veins fused to form an enlarged ascending lumbar vein, draining blood from the lower limbs to the suprarenal inferior vena cava. On the right, prominent collateral veins were present in the groin, and the enlarged hyperdense tortuous collateral vein was seen to communicate with the right ascending lumbar vein (Fig. 2E).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C. —22-year-old man with infrarenal absence of inferior vena cava and thrombosis of right pelvic collateral vein mimicking acute appendicitis. Unenhanced CT image shows distended, tortuous, hyperdense, thrombosed venous collateral vessel (arrow) with surrounding inflammatory change.

View larger version (88K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D. —22-year-old man with infrarenal absence of inferior vena cava and thrombosis of right pelvic collateral vein mimicking acute appendicitis. Unenhanced CT image shows absence of infrarenal inferior vena cava. Note presence of normal aorta (arrow).

View larger version (87K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2E. —22-year-old man with infrarenal absence of inferior vena cava and thrombosis of right pelvic collateral vein mimicking acute appendicitis. Unenhanced CT image shows dilated ascending lumbar veins (arrowheads) that drain blood from lower limbs. Note normal common iliac arteries (arrows) but absence of common iliac veins.

The findings are those of thrombophlebitis of a right pelvic collateral vein. MDCT performed 1 year previously confirmed the anomalous anatomy but absence of the thrombosis. Further Doppler sonography was performed to evaluate the veins of both legs. The collateral venous channels in the right groin were patent, but no normal common femoral vein was seen. The superficial femoral and popliteal veins were patent. The left common femoral, superficial femoral, and popliteal veins were also patent.

Deep venous thrombosis is a recognized complication of inferior vena cava anomalies. Such anomalies should therefore be suspected in all cases of deep vein thrombosis, especially if bilateral, in young patients [1]. Venous stasis due to inadequate venous return despite prominent collateral vessels has been postulated as a possible mechanism of thrombosis in such cases [1]. A few reports exist of ovarian vein thrombosis mimicking appendicitis on helical CT and sonography [2, 3], but we found no other reports of an anomalous inferior vena cava with thrombosis of a collateral vessel mimicking appendicitis. In this case, the presence of a tender, noncompressible tubular structure in the right iliac fossa with surrounding free fluid and inflammatory fat was suspected to be acute appendicitis. The absence of some cardinal features of appendicitis, such as a blind-ending tube and connection with the cecum, made a definitive diagnosis on sonography difficult [4]. In such cases it may be prudent to perform helical CT, which in this case revealed pelvic venous thrombosis mimicking appendicitis. Obviously the treatment is completely different for these two entities. The patient avoided unnecessary surgery and was treated conservatively with anticoagulants.

References

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1. Gayer G, Luboshitz J, Hertz M, et al. Congenital anomalies of the inferior vena cava revealed on CT in patients with deep venous thrombosis. AJR 2003;180:729 –732[Abstract/Free Full Text]
2. Van Hoe L, Baert AL, Marchal G, Spitz B, Penninckx F. Thrombosed ovarian vein collateral mimicking acute appendicitis on CT. J Comput Assist Tomogr 1994;18:643 –646[Medline]
3. Adkins J, Wilson S. Unusual course of the gonadal vein: a case report of post-partum ovarian vein thrombosis mimicking acute appendicitis clinically and sonographically. J Ultrasound Med1996; 15:409 –412[Medline]
4. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology2000; 215:337 –348[Abstract/Free Full Text]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Moulding, F. J. Articles by Hanbidge, A. E. Search for Related Content PubMed PubMed Citation Articles by Moulding, F. J. Articles by Hanbidge, A. E. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?