Abdominal Pain Following Lap‐Sleeve Gastrectomy: A Case of Post‐Operative Portal Vein Thrombosis

Case Presentation:

A 25‐year‐old female with a history of polycystic ovarian syndrome, obesity and laparoscopic sleeve gastrectomy two weeks prior presented to the Emergency Department with complaints of lower groin pain and flank pain x 3 days. She reported 8/10 constant pain, associated with nausea. She denied fevers, chills, vomiting, diarrhea, dysuria, hematuria, vaginal bleeding or discharge. Vital signs showed heart rate 112, blood pressure 110/71, temperature 36.6, respiratory rate 12 and oxygen saturation 97% on room air. Her abdomen was tender to palpation of her bilateral lower quadrants, left greater than right, without rebound, guarding or costo‐vertebral tenderness. Pelvic exam demonstrated bilateral adnexal tenderness without masses and no cervical motion tenderness. Transvaginal ultrasound showed complex pelvic fluid in the cul‐de‐sac and left adnexa. The patient was admitted to medicine with presumed ruptured ovarian cyst for pain control and hydration. On hospital day 2, her pain acutely worsened and localized to the right and left mid‐back and flank area without abdominal pain. A non‐contrast abdomen/pelvis CT reported possible mesenteric adenitis and dilatation of the branches of the superior mesenteric vein (SMV). MR venogram demonstrated thrombosis of the portal vein and SMV extending into the splenic vein. The patient was started on a heparin drip and her pain improved by hospital day 4. Of note, a hypercoaguable work‐up checked as part of her pre‐operative exam was negative. She was discharged home on hospital day #6 on therapeutic warfarin.

Discussion:

Post‐operative portal vein thrombosis (PVT) is a known complication of intra‐abdominal surgeries requiring manipulation of porto‐mesenteric veins.¹ However, PVT has been increasingly reported with laparascopic surgeries including appendectomy, cholystectomy, colectomy and Nissin fundoplication.² Two other cases of PVT have been reported following lap‐sleeve gastrectomy. A proposed mechanism for post‐laparoscopy PVT is that increased intra‐abdominal pressure from procedural pneumoperitoneum leads to venous stasis of the portal system, predisposing to thrombosis.³

Conclusions:

PVT is an important complication of laparoscopic procedures that do not directly manipulate the portal veins. PVT should be suspected in post‐operative patients with vague abdominal symptoms, severe abdominal pain, signs of mesenteric ischemia or new ascites. Diagnosis can be made via ultrasound with doppler, CT or MR venogram.

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• 3. Rosenberg JM, Tedesco M, Yao DC, Eisenberg D. Portal vein thrombosis following laparoscopic sleeve gastrectomy for morbid obesity. J Soc Lap Surg. 2012; 16(4): 639–643.