Abdominal vessel thrombosis is a rare complication of antiphospholipid syndrome. It usually affects the hepatic vessels, but less frequently the intestinal, spleen, or pancreas vessels. The most common digestive system manifestation of antiphospholipid syndrome is Budd–Chiari syndrome (BCS) that refers to the obstruction of hepatic venous outflow of major hepatic veins [
9,
10]. The clinical presentation ranges from an asymptomatic condition to fulminant liver failure but usually shows itself as abdominal pain, ascites, and hepatomegaly [
11,
12]. In terms of etiology, primary and secondary types of BCS can be distinguished. Primary BCS is associated with the existence of thrombotic risk factors while secondary is often due to extrinsic compression and tumor infiltration [
13‐
15]. APS can also manifest itself as mesenteric and celiac trunk thrombosis. Rosenthal et al. documented a case of a 39-year old woman diagnosed with SLE and secondary Sjogren’s syndrome, recurrent abdominal pain, and reduced appetite. During the analysis, a very tight stenosis of the celiac artery of > 90% was noted. She was treated with warfarin with a target INR of 3–4 until a clinical improvement was obtained [
16]. Shirish et al. reported that celiac and mesenteric stenosis were most commonly found in atherosclerotic patients [
17]. Among all the manifestations of antiphospholipid syndrome, spleen or pancreatitis infarction are distinguished less frequently. Following this, the first case of pancreatic involvement in association with aPL was described by Bird et al., in a patient with severe, intravascular coagulation. The patient had a history of recurrent miscarriage. Consequently, the diagnostic process was conducted, and lupus anticoagulant, anticardiolipin antibodies showed to be positive. In another study of 89 patients with spleen infarction, 39% of them had APS [
5,
18].
APS includes a wide range of thrombotic manifestations of the digestive system. However, during a differential diagnosis of abdominal vessel stenosis, it is necessary to exclude certain conditions such as MALS which presumably trigger the thrombotic event, especially with young populations without comorbidities as such atherosclerosis. The carried research showed that MALS may disrupt the hepatic artery hemodynamics and reduce hepatic blood flow velocity in patient with liver transplants [
18‐
20,
28]. Typical tests that allow differential diagnosis include Doppler ultrasound, CT, and MR [
1,
4]. Doppler ultrasonography can be an excellent screening tool. Once the diagnosis of MALS is suspected, it can show the blood flow changes of the celiac trunk, its flexion during respiration, and diaphragmatic excursion. [
3,
4,
21]. In indication to other condition as BCS, Doppler ultrasonography can point out the narrowing of blood veins [
22]. Moreover, in particular cases, we can observe an overlap syndrome where the diagnostic process is challenging. Diagnosing and treating antiphospholipid syndrome concomitant with other conditions may involve close collaboration between the radiologist, surgeon, and rheumatologist. However, the background therapy includes vitamin K antagonists (VKA), with a target of INR 2–3. For those with recurrent thrombosis and a minor risk of bleeding, the insertion of low-dose aspirin (75–100 mg) or the upregulation of the VKA dose with the target of INR 3–4 should be considered [
6,
7,
23].There is no substantial evidence for using an alternative way of therapy with NOACs (non-vitamin K oral anticoagulants). Patients treated with NOACs, with regard to those taking VKA, are at a higher risk of recurrence of thromboembolism and bleeding events, especially with triple aPl positivity or arterial thrombosis. The recurrent events mostly occur in the arterial circulation ischemic such as strokes and myocardial infarction [
23‐
27]. Nevertheless, there have been reported cases of APS that NOAC therapy can be beneficial [
26]. Cohen et al. published a randomized controlled trial where non-inferior NOACs to VKA were concluded [
26]. Based on the above, it is not recommended to implement NOACs as standard anticoagulant therapy; however, it can be considered as a treatment for those who cannot use VKA or are not able to reach the recommended INR level. The proper treatment strategy may be under consideration according to the patient's current condition, although long-term anticoagulant treatment is recommended, especially for patients with secondary APS. Additional therapy with hydroxychloroquine, vitamin D, statins, and sirolimus is also considered for thrombotic APS but that requires further analysis [
23‐
27]. The other aspect that links APS with the gastrointestinal tract is gut microbiota. There are reports that microbiota may have a deep impact on the autoimmunological system and pathogenesis of immune diseases like APS in susceptible patients. In healthy individuals, the microbiota maintains an anti-inflammatory environment as opposed to when homeostasis is impaired and pro-inflammatory interactions predominate. A profound understanding of those interactions could conduct new ways of prevention, diagnosis, and treatment of APS patients [
28,
29].