Portomesenteric Venous Thrombosis in an Emergency Department Patient After Laparoscopic Sleeve Gastrectomy

Abstract

Postoperative abdominal pain after gastric surgery requires thorough evaluation in the ED. Portomesenteric venous thrombosis (PMVT) is a rare complication after laparoscopic sleeve gastrectomy, which requires prompt evaluation and diagnosis. Patients require admission with prompt anticoagulation and broad-spectrum antibiotics due to the risk of decompensation from intestinal ischemia and sepsis from bowel translocation. This report describes the case of a 36-year-old male who presented to the ED one week after laparoscopic sleeve gastrectomy with tachycardia and gradual onset, severe, sharp epigastric abdominal pain associated with anorexia and fatigue. He subsequently developed hypotension requiring vasopressor support, acute kidney injury, thrombocytopenia, and septic shock suspected due to secondary to bowel translocation. He was transferred to another facility for consideration for thrombolysis and went on to recover. This case report describes a rare case of PMVT after laparoscopic sleeve gastrectomy. Surgical risk factors include obesity and multiple components of Virchow's triad. These include inherited/acquired thrombophilic states, iatrogenic endothelial injury of portal vein/mesenteric vessels via direct manipulation, and increased intraabdominal pressure decreasing portal venous flow. Providers should carefully consider evaluation for genetic hypercoagulability requiring lifelong anticoagulation. On hospital discharge, anticoagulation should continue for at least six months, with repeat CT with IV contrast or USG in three to six months to evaluate for recanalization of the venous system. Knowledge of the appropriate evaluation and treatment of this rare complication after laparoscopic sleeve gastrectomy is vital to avoid unnecessary patient morbidity and mortality.