Bariatric Times

JUN 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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19 Case Report and Literature Review Bariatric Times • June 2017 t herapy [CPAP]), gastroesophageal reflux disease (GERD), alpha thalassemia (a blood disorder that reduces the production of hemoglobin), depression, and m orbid obesity. Her medications at the time of presentatin were as follows: aspirin 81mg daily, omeprazole 40mg PO (by mouth) daily, bupropion 300mg PO daily, f luticasone/salmetrol inhaler, levalbuterol, montelukast, ondansetron, loratidine, and an oral contraceptive pill (OCP [ethinyl estradiol and levonorgestrel]). P atient reported that she had been on the OCP for 10 to 15 years except during pregnancy; she had two full-term pregnancies. She stopped taking the medication prior t o several days prior to surgery as per pre-operative instructions. Her past surgical history was significant for a recent laparoscopic sleeve gastrectomy and hiatal h ernia repair with anterior cruroplasty (2015) laparoscopic cholecystectomy (2004), and two caesarian sections (2002, 2008). She was a former smoker (1pack per day for 15 years), having quit one year prior to presentation (quit date of 8/2014). She denied alcohol or recreational drug use. Her family medical history was unknown given that she was adopted. Upon arrival to the emergency room, the patient was hemodynamically stable. Her physical exam was only remarkable for tenderness to palpation in the epigastric region, right upper quadrant and left lower quadrant without peritoneal signs. Her recent surgical incisions were all healing well without erythema or drainage. Laboratory findings were significant for leukocytosis (15.45 k/mm), thrombocytosis (526 k/mm), and elevated ALT (983 U/L), AST (647 U/L), and alkaline phosphatase (147 U/L). Her lipase, electrolytes, urinalysis, and hepatitis viral panel were all within normal limits. An initial computerized tomography (CT)scan of her abdomen with PO contrast showed clear lung bases, and no abnormality of the spleen, pancreas, or adrenal glands. The portal venous system demonstrated hypoattenuation and mild dilation with adjacent stranding beginning at the confluence of the superior mesenteric and splenic veins consistent with an extensive acute portal venous thrombosis (PVT). There was no intrahepatic biliary ductal dilation (Figure 1). The gastric sleeve was without evidence of obstruction or contrast extravasation. There was no adjacent stranding or fluid (Figure 2). There were several diverticula noted throughout the colon. Within the sigmoid colon there was an area of complex fluid collection with a s mall tract extending toward the collection. The complex collection of fluid and gas anterior to the uterus and superior to the urinary bladder measuring 5 x 5.2 x 4 cm w ith significant fat stranding noted around the collection (Figure 3). There was no evidence of a high- grade obstruction or mural thickening. There was no free air in t he peritoneal cavity. She was started on therapeutic low-molecular weight heparin (LMWH)and was treated for her pelvic abscess. The collection was d rained by interventional radiology (IR). Subsequent tube studies showed a communicating fistula between the abscess cavity and the colon. She displayed improvement f ollowing the drainage of the abscess and was discharged home on therapeutic anticoagulation (Figure 3). Two weeks following drain r emoval she presented again with the same symptoms. A repeat CT scan showed another fluid collection in the left lower quadrant and showed that the PVT remained s table and was beginning to decrease in caliber. The thrombosis of the peripheral branches of the portal vein were unchanged. There was an increase in the caliber of m ultiple collateral vessels in the porta hepatis, which was compatible with cavernous transformation (Figure 4). The new fluid collection was again drained b y IR. Following these imaging studies, the care team decided to leave the drain in place until the patient's colon resection was completed.

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