First differentiated from arterial causes of acute mesenteric ischemia 75 years ago, acute mesenteric venous thrombosis (MVT) is an uncommon disorder with non-specific signs and symptoms, the diagnosis of which requires a high index of suspicion. The location, extent, and rapidity of thrombus formation determine whether intestinal infarction ensues. Etiologies, when identified, usually can be separated into local intra-abdominal factors and inherited or acquired hypercoagulable states. The diagnosis is most often made by contrast-enhanced computed tomography, though angiography and exploratory surgery still have important diagnostic as well as therapeutic roles. Anticoagulation prevents clot propagation and is associated with decreased recurrence and mortality. Thrombectomy and thrombolysis may preserve questionably viable bowel and should be considered under certain circumstances. Evidence of infarction mandates surgery and resection whenever feasible. Although its mortality rate has fallen over time, acute MVT remains a life-threatening condition requiring rapid diagnosis and aggressive management. Chronic MVT may manifest with complications of portal hypertension or may be diagnosed incidentally by noninvasive imaging. Management of chronic MVT is directed against variceal hemorrhage and includes anticoagulation when appropriate; mortality is largely dependent on the underlying risk factor.

This issue provides a clinical overview of gastroesophageal reflux disease, focusing on diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Streptococcus bovis bacteremia has been linked to the presence of occult colon cancer since 1977. We present a case of pyogenic liver abscess and bacteremia with a different Streptococcus viridans 1 week after colonic adenocarcinoma was removed via polypectomy, discuss the likely etiology and review whether there is evidence to support looking for colon cancer in patients who present similarly but have not already undergone screening.

A 44-year-old woman with hepatitis C cirrhosis presented with a week of heavy vaginal bleeding. Her obstetric history was significant for three cesarean sections. Her gynecologist made an initial diagnosis of menometrorrhagia exacerbated by thrombocytopenia and coagulopathy. Computed tomography (CT) angiography revealed splenic vein thrombosis and engorged pelvic veins which arose as collaterals from the splenic vein ( Fig. 1). Hysteroscopy could not identify a culprit lesion due to the rapidity of bleeding.A transjugular intrahepatic portosystemic shunt (TIPS) was created and thrombectomy of the splenic vein was performed and the residual partially occlusive thrombus was then stented. Hepatopedal flow was then noted from splenic vein to portal vein and through the TIPS. Hysteroscopy showed persistently engorged varices. Venous embolization of the varices was performed with a combination of embolization coils and a vascular plug (Fig. 2). Recovery was uneventful, and she was followed for 2 years in our clinic without further vaginal bleeding. DiscussionVaginal bleeding due to portal hypertensive collaterals is a rare presentation in patients with cirrhosis. The first case was reported in 1967, in a cirrhosis patient with a history of total abdominal hysterectomy. They theorized that the varices formed within fibrous adhesions present as a result of the patient's prior surgery, a phenomenon that might have been similar to our case. At surgery, their patient had a dilated right hypogastric vein that communicated with several varicosities in the vaginal vault. Treatment consisted of ligation and partial vaginectomy.When present, pelvic varices are typically multiple, ipsilateral, and dilated to at least 4 mm in diameter. 2The rarity of parauterine or vaginal varices is accounted for by several factors. First, portal hypertensive collaterals typically drain to the external iliac veins rather than to the internal iliac veins, whereby pelvic veins are dilated. Second, both the uterus and vagina have extensive venous plexuses draining to the hypogastric veins, which are part of the systemic circulation, thus adequately decompressing high pressure pelvic blood flow. However, perturbation or removal of the uterine plexus via surgery or scarring may leave the vaginal plexus insufficient to decompress shunted blood flow back into the systemic circulation, resulting Abbreviations: CT, computed tomography; TIPS, transjugular intrahepatic portosystemic shunt.From the NY Association in Gastroenterology, Bronx, NY Address reprint requests to: Hatef Massoumi, NY Assoc in Gastroenterology,

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