Two Pediatric Patients with Splanchnic Venous Thrombosis as a Complication of Acute Pancreatitis Successfully Treated with Low-Molecular-Weight Heparin and Rivaroxaban

Case series Patients: Female, 13-year-old • Female, 9-year-old Final Diagnosis: Pediatric acute recurrent pancreatitis • splanchnic venous thrombosis involving the splenic vein Symptoms: Abdominal pain Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology • Pediatrics and Neonatology OBJECTIVE: Unusual clinical course BACKGROUND: Splanchnic venous thrombosis is a known complication of pancreatitis in children and can involve the splenic, portal, or superior mesenteric veins, either in isolation or in combination. However, diagnosis and management of thrombosis following pancreatitis remains controversial, especially regarding the use of anticoagulants for management. Here, we present the cases of 2 children who developed splanchnic vein thrombosis involving the splenic vein during attacks of pancreatitis and who were successfully treated with direct oral anticoagulants. CASE REPORTS: Case 1: A 13-year-old girl presented with a second attack of acute pancreatitis. She developed a non-occlusive splenic vein thrombosis diagnosed by CT scan on the sixth day of hospitalization. Injectable low-molecular-weight heparin was started during hospitalization and switched to oral rivaroxaban at discharge. Imaging at follow-up showed resolution of thrombosis. Case 2: A 9-year-old girl with history of acute recurrent pancreatitis presented with a third attack of acute pancreatitis. An occlusive splenic vein thrombosis with extension into the portal vein and superior mesenteric vein and necrotizing pancreatitis was seen on CT scan on the third day of hospitalization. Low-molecular-weight heparin was initiated during hospitalization and was switched to oral rivaroxaban at discharge. Imaging at follow-up demonstrated nearly complete resolution of the extensive thrombosis. CONCLUSIONS: Splanchnic venous thrombosis remains a rare complication of pediatric pancreatitis. Anticoagulant use in patients with these complications remains controversial. Direct oral anticoagulants are as safe and effective as low-molecular-weight heparin and should be considered for use in children instead of low-molecular-weight heparin due to its advantages, including the availability of enteral forms of administration.