P4797 - Acute Portal Vein Thrombosis After Laparoscopic Roux-en-Y Gastric Bypass

Joyce Lee, MD¹, Emily Smith, MD², David Wan, MD^3
1New York-Presbyterian / Weill Cornell Medical Center, Boston, MA; ²New York-Presbyterian/Weill Cornell, New York, NY; ³New York-Presbyterian / Weill Cornell Medical Center, New York, NY

Introduction: Although uncommon, portal vein thrombosis (PVT) is associated with high morbidity and mortality, with most common causes including cirrhosis and hypercoagulable states. The clinical presentation of acute PVT is relatively nonspecific, but early diagnosis and treatment can prevent severe complications such as bowel infarction and portal hypertension. Here we present a rare case of acute PVT after a laparoscopic Roux-en-Y gastric bypass.

Case Description/Methods: A 45-year-old female with a medical history of hypertension and obesity s/p laparoscopic Roux-en-Y gastric bypass presented on post-op day 15 with a 4-day history of poor oral intake, dyspnea and right lower quadrant (RLQ) pain. Vital signs were within normal limits. Physical exam was notable for RLQ discomfort with no rebound or guarding. Labs on presentation, including complete blood count, basic metabolic panel, liver tests, and coagulation studies were within normal limits. She had no personal or family history of clotting disorders. Anticardiolipin antibody, beta-2 glycoprotein, JAK2 V617F, JAK2 exon 12, and PNH workup were negative. CT of the abdomen and pelvis with IV contrast indicated left portal vein occlusion with adjacent irregular hypodensity suggestive of possible infarction and a sub-centimeter wedge-shaped subcapsular hypodensity in the mid-spleen. Imaging was negative for other biliary or liver disease. Given the patient’s symptoms and negative workup for other causes of thrombosis, provoked acute PVT in the setting of recent abdominal surgery was highly suspected. The patient was initially treated with enoxaparin and was planned to transition to therapeutic warfarin, which was the patient’s preferred outpatient anticoagulation, but she ultimately did not take warfarin post-discharge due to lack of follow-up. The subsequent course was uneventful.

Discussion: Acute PVT can be diagnosed based on reported symptoms (i.e. abdominal pain), physical examination, laboratory testing and/or abdominal imaging. There is literature by Carrano et al. reporting Roux-en-Y gastric bypass as the second most associated bariatric surgery with provoked PVTs, but post-sleeve gastrectomy PVTs are more common and better characterized. In this post-op patient with nonspecific symptoms and normal lab values, a high index of suspicion for acute PVT and early identification via abdominal imaging were confirmatory for identifying this rare but life-threatening complication of bariatric surgery.


Disclosures:


Joyce Lee, MD¹, Emily Smith, MD², David Wan, MD³. P4797 - Acute Portal Vein Thrombosis After Laparoscopic Roux-en-Y Gastric Bypass, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.