A Survivor of Chronic Disseminated Intravascular Coagulation (DIC) after a Gastric Bypass Surgery

Case Report

Austin J Clin Case Rep. 2014;1(9): 1042.

A Survivor of Chronic Disseminated Intravascular Coagulation (DIC) after a Gastric Bypass Surgery

Li W*, Salcedo V, Buendia J and Le C

Department of Family and Community Medicine, Texas Tech University Health Science Center, USA

*Corresponding author: Li W, Department of Family and Community Medicine, Texas Tech University Health Science Center, Odessa, TX 79763, USA

Received: July 31, 2014; Accepted: September 01, 2014; Published: September 03, 2014

Abstract

Though, the overall risk of death and adverse outcomes after bariatric surgery is low, the severity of complications and related mortality should never be underestimated. Here we report a 59-year-old Caucasian female who suffered but survived from chronic disseminated intravascular coagulation (DIC) three months after her laparoscopic Roux-en-Y gastric bypass (RYGBP) surgery. The patient developed intra-abdominal abscess and multiple venous thromboses. Most of workup for coagulopathy was negative except elevated D-dimer and fibrinogen to 2841 ng/ml and 860 mg/dL respectively. A chronic DIC was diagnosed. The patient was put on a heparin drip after exploratory laparotomy. Then she was successfully bridged to Coumadin and discharged. Surgical patients for gastric bypass with higher risks of venous thrombosis should be considered for aggressive peri-operative prophylactic anti-coagulation, and lower threshold for early work up.

Keywords: Chronic Disseminated Intravascular Coagulation (DIC); Gastric bypass surgery; Venous thrombosis; Venous Thromboembolism prophylaxis

Abbreviations

DIC: Chronic Disseminated Intravascular Coagulation; RYGBP: Roux-en-Y Gastric Bypass; VTE: Venous Thromboembolism

Case Presentation

This is a 59-year-old Caucasian female who presented to our emergency department because of abdominal pain that was worsening for 3 days. The patient had a BMI of 49.6 kg/m2 and received RYGBP gastric bypass surgery on August 15, 2013 at a hospital in New Mexico. After 5 days’ hospital course, the patient was discharged home uneventfully. She then followed up with his primary care physician in a different city in New Mexico on September 20 with a complaint of left upper quadrant and lower chest pain. CT of the abdomen and chest on the same day showed left pleural effusion, however no mass or other abnormality. A thoracentesis was performed and the cytology revealed reactive mesothelial cells in transudate. Cultures were negative for bacteria, AFB or fungi. Two weeks later, the patient experienced generalized abdominal pain, worsening over the following three days, accompanied by nausea, vomiting and diarrhea. She also complained of anorexia and weakness. Then patient came to our emergency department (ED), a university hospital in Texas on October 12, 2013. At initial assessment, patient’s vital signs were stable except for mild tachycardia. She appeared drowsy, lethargic and dehydrated. A generalized tenderness of abdomen was present. Laboratory studies showed leukocytosis and hypoalbuminemia. An CAT scan with intravenous contrast in ED was suggestive of multiple thrombosis of the superior mesenteric vein, portosplenic confluence, main portal vein, right and left portal veins, and splenic vein as well as multiple infarcts of the spleen and liver (Figure 1), multiple abscesses along the residual stomach and spleen (Figure 2), and mild left pleural effusion. A full workup for coagulopathy was performed. During admission, the patient developed acute abdomen and deteriorated quickly. General surgery was consulted and he suspected “peritonitis”, “small intestinal ischemia” and “portal vein thrombosis, splenic vein thrombosis, superior mesenteric vein thrombosis”. The general surgeon decided to perform an exploratory laparotomy emergently. The postoperative diagnoses were “left upper quadrant/left subdiaphragmatic abscess” and “Jejunal perforation at gastrojejunal anastomosis”. The general surgeon performed a laparotomy with “drainage of intra-abdominal abscess”, “Enterorrhaphy gastrojejunal anastomosis” and “insertion of 16-French jejunostomy feeding tube”. Unfractionated heparin instead of low molecular heparin was initiated as anti-coagulant postoperatively due to acute kidney injury. The coagulopathy studies came back later, included antinuclear antibody, rheumatoid factor, homocysteine level, lupus anticoagulant panel, protein C and protein S assay, cardiolipin antigen and antibodies, factor V Leiden mutation assay, complement 3 and 4 levels, prothrombin F2 gene mutation, MTHFR mutation C677T and MTHFR mutation A1298C assays. Though the dilute Russell’s viper venom time (dRVVT) screen test was abnormal in the lupus anticoagulant panel, the dRVVT MIX CONFIRM test was normal. All other tests were within normal limits, however, elevated D-dimer and fibrinogen of 2841 ng/ml and 860 mg/dL were observed. A diagnosis of chronic DIC secondary to VTE and intra-abdominal abscess was made.

Citation: Li W, Salcedo V, Buendia J and Le C. A Survivor of Chronic Disseminated Intravascular Coagulation (DIC) after a Gastric Bypass Surgery. Austin J Clin Case Rep. 2014;1(9): 1042. ISSN 2381-912X