Idiopathic Myointimal Hyperplasia of the Mesenteric Veins Is a Peculiar Venous Ischemia That May Be Diagnosed Before Surgery

Abstract

BACKGROUND: Idiopathic myointimal hyperplasia of the mesenteric veins is a segmental ischemia associated with noninflammatory hyperplasia of the intimal smooth muscle of the mesenteric veins. Owing to its rarity, timely diagnosis is often difficult.

OBJECTIVE: The goal of this study was to improve clinical practice in terms of the diagnosis of idiopathic myointimal hyperplasia of the mesenteric veins.

DESIGN: This was a retrospective observational study.

SETTINGS: This study was conducted in a single institution with case collection from clinical archives.

PATIENTS: Data from 12 cases of idiopathic myointimal hyperplasia of the mesenteric veins were retrieved from 2006–2020. Most patients were elderly men, with a male-to-female ratio of 10:1.

MAIN OUTCOME MEASURES: Clinical, endoscopic, radiologic, and pathologic characteristics of idiopathic myointimal hyperplasia of the mesenteric veins served as outcome measures.

RESULTS: Radiologically, marked segmental mural thickening and poor enhancement involved the sigmoid colon and rectum in most cases, with extension to the descending colon in some cases. Typical cases showed obliteration of the inferior mesenteric veins and collateral vessels. Colonoscopic findings were reminiscent of ischemia or ulcerative colitis, but sharp demarcation from the uninvolved segment was the most distinguishing feature. Surgically resected specimens showed marked segmental mural thickening, edema, and mucosal discoloration grossly. Microscopically, thick-walled, tortuous veins were observed mainly in the submucosa and subserosa, and the submucosa was markedly thickened in all cases. The subserosal large veins showed myointimal hyperplasia, and pericolic fat necrosis was invariably observed. The most useful histologic finding in biopsy material was tortuous, arteriolized mucosal capillaries with occasional fibrinoid necrosis.

LIMITATIONS: This study was limited by its small number of cases and selection bias; there was also no prospective external validation.

CONCLUSIONS: Radiologic and pathologic features of idiopathic myointimal hyperplasia of the mesenteric veins are distinct from those of ulcerative colitis or nonspecific ischemic colitis. Careful interpretation of endoscopic and radiologic images and generous biopsies with interpretation by experienced pathologists might lead to an early diagnosis and prevent unnecessary medical treatment.