Intraluminal Blood Clot Research Articles

A277 Small Bowel Obstruction from Intraluminal Blood Clot in LVAD Patient after Laparoscopic Roux-en-Y Gastric Bypass

A277 Small Bowel Obstruction from Intraluminal Blood Clot in LVAD Patient after Laparoscopic Roux-en-Y Gastric Bypass

Acute urethral obstruction in a breeding ram associated with throughout intra-luminal blood clots and severe azotemia

Acute urethral obstruction in a breeding ram associated with throughout intra-luminal blood clots and severe azotemia

Endovascular coil embolization of inferior mesenteric artery to ileal-conduit fistula: a case report

BackgroundUretero-arterial fistulas (UAFs) are uncommon and pose a diagnostic dilemma, making them life threatening if not recognized and treated expediently. UAFs to small arteries such as a branch of the inferior mesenteric artery (IMA) are very uncommon and present a further diagnostic and treatment challenge. There should be a high index of suspicion for UAFs when intervening on patients with history of treated pelvic cancers and long-standing ureteric stents experiencing hematuria not attributable to another cause.Case presentationWe present a case of a fistula formed between a distal branch of the IMA—superior rectal artery—and an ileal-conduit in a patient with a long-standing reverse nephroureterostomy (Hobbs) catheter presenting with abdominal pain and hematuria through the conduit. During a tube exchange, contrast injection demonstrated a fistula with the superior rectal artery, multiple ileal intraluminal blood clots, and active extravasation. The patient became tachycardic and hypotensive, actively bleeding through the ileal-conduit, prompting a massive transfusion protocol. Successful endovascular coiling of the superior rectal artery was performed with resolution of active extravasation and stabilization of the patient. The patient recovered and was discharged in stable condition 10 days later.ConclusionsAlthough UAFs are uncommon, our case demonstrated key predisposing risk factors to fistula development; pelvic cancer surgery, pelvic radiation, and a prolonged ureteric stent through the ileal-conduit. Typically, UAFs arise from communication with the iliac arterial system, however in this instance we have demonstrated that fistulization to other arterial vessels is also possible. Endovascular management has become the preferred method of therapy, typically involving the placement of covered stents when involving the iliac arterial system. In this instance stent grafting was not possible due to the small caliber vessel and therefore had to be embolized.

Organ Donation From a Brain Dead Donor With Vaccine-induced Immune Thrombotic Thrombocytopenia After Ad26.COV2.S: The Risk of Organ Microthrombi.

Organ Donation From a Brain Dead Donor With Vaccine-induced Immune Thrombotic Thrombocytopenia After Ad26.COV2.S: The Risk of Organ Microthrombi.

Reversed diastolic flow in a renal transplant due to ureteric obstruction from intraluminal blood clot

AbstractReversal of arterial diastolic flow is commonly considered a sign of transplant renal vein thrombosis until proven otherwise, with the differential including acute rejection, acute tubular necrosis, and perirenal hematoma. We discuss a case of a patient who presented with decreased urine output on the second postoperative day following living unrelated kidney transplantation. Doppler ultrasound was performed and demonstrated reversal of diastolic flow in the transplant renal artery. Prompt surgical exploration revealed intraluminal blood clot obstructing the ureter. To our knowledge, this is the first reported case of reversed diastolic flow secondary to ureteral obstruction by an intraluminal blood clot.

Blood clot causing small bowel obstruction after Roux en-Y Gastric bypass: a Case Report & Review of Literature

The gold standard procedure and most commonly performed bariatric surgery internationally is the Roux En-Y Gastric Bypass (RYBG) surgery. A major complication of the RYGB is small bowel obstruction (SBO; 5% incidence), most frequently caused by intra-abdominal adhesions (65–75%), followed by internal hernias, volvulus, malignancy, intussusception, Crohn’s disease, carcinomatosis, intraluminal blood clot, port site hernias, jejunojejunostomy anastomosis strictures, paralytic ileus, and superior mesenteric artery syndrome. In this review of literature, we present a small bowl obstruction case caused by a blood clot (inside the lumen) at a bleeding site within a jejunojejunostomy staple line of a surgical patient. The patient’s past-medical history is significant for recurrent deep venous thrombosis (DVT) and pulmonary embolism (PE). The SBO was diagnosed by computed tomography (CT) post-operatively and the patient underwent emergent explorative laparoscopy for management. The intraluminal clot that was found upon examination was evacuated by enterotomy followed by a primary closure with no evidence of continued active bleeding and without need for revision of the jejunojejunal anastomosis. It was concluded that the anti-coagulant medication (Enoxaparin 50 mg BID) being administered to the patient most likely precipitated the intraluminal bleeding at the anastomosis. Based on our findings, early diagnosis and management of SBO in the early perioperative period could likely reduce the percent of this in bariatric patients.

Blood clot causing small bowel obstruction after Roux en-Y Gastric bypass: a Case Report & Review of Literature

The gold standard procedure and most commonly performed bariatric surgery internationally is the Roux En-Y Gastric Bypass (RYBG) surgery. A major complication of the RYGB is small bowel obstruction (SBO; 5% incidence), most frequently caused by intra-abdominal adhesions (65–75%), followed by internal hernias, volvulus, malignancy, intussusception, Crohn’s disease, carcinomatosis, intraluminal blood clot, port site hernias, jejunojejunostomy anastomosis strictures, paralytic ileus, and superior mesenteric artery syndrome. In this review of literature, we present a small bowl obstruction case caused by a blood clot (inside the lumen) at a bleeding site within a jejunojejunostomy staple line of a surgical patient. The patient’s past-medical history is significant for recurrent deep venous thrombosis (DVT) and pulmonary embolism (PE). The SBO was diagnosed by computed tomography (CT) post-operatively and the patient underwent emergent explorative laparoscopy for management. The intraluminal clot that was found upon examination was evacuated by enterotomy followed by a primary closure with no evidence of continued active bleeding and without need for revision of the jejunojejunal anastomosis. It was concluded that the anti-coagulant medication (Enoxaparin 50 mg BID) being administered to the patient most likely precipitated the intraluminal bleeding at the anastomosis. Based on our findings, early diagnosis and management of SBO in the early perioperative period could likely reduce the percent of this in bariatric patients.

Pathological findings of hemorrhagic bowel syndrome (HBS) in six dairy cattle cases.

Six adult dairy cows clinically diagnosed as hemorrhagic bowel syndrome (HBS) were the subjects of this study. The involved intestinal lesions were fixed in formalin and examined macroscopically and histopathologically. Pathological examinations revealed large intramural hematomas with necrotic foci, resulting in luminal obstruction. The mucosal layer in the lesions was detached from the intestinal wall, and there were no hemorrhagic changes in the lumen. The intramural hematomas were sometimes covered with histologically intact mucosal layer. These pathological findings were not consistent with those of “intraluminal blood clots” reported previously. Gram-positive and anti-Clostridium antibody-positive short bacilli were found in hemorrhagic necrotic areas. However, the exact relationship between Clostridium spp. observed in the lesions and HBS remains unclear, because this bacterium is a normal inhabitant in cattle.

Gastro-jejunal Obstruction Caused by Clotting after Gastric Bypass Surgery: A Case Series

Purpose: One of the most frequent surgical modalities for the treatment of obesity is the Roux-en-Y gastric bypass (RYGB). Previously described complications of RYGB include stomal stenosis, gastric staple line dehiscence, leaks, jejunal and gastric wall necrosis, and loculated fluid collections. Another reported complication is post-operative intraluminal bleeding, which is usually self-limiting. However, it is uncommon to encounter early gastric outlet obstruction secondary to intraluminal blood clots. Intraluminal blood clot formation causing obstruction post RYGB has been reported in only a few case reports, where management predominantly included laparotomy and surgical revision. We report a case series of three patients who developed intraluminal blood clots at the gastro-jejunal anastomosis following robotically-assisted RYGB occurring within 72 hours of surgery. Our first case involves a 63-year-old woman with morbid obesity (BMI 42) who presented with persistent nausea and vomiting for 3 days after an elective, robotically-assisted RYGB and laparoscopic lysis of adhesions. After the procedure, the patient underwent a routine upper GI series without evidence of leakage from the visualized pouch; however, there was no evidence of emptying into the alimentary limb. Physical exam revealed a distended abdomen which was appropriately tender to palpation at the surgical site. EGD was performed and a large blood clot was visualized at the anastomotic site, causing a gastric outlet obstruction. After unsuccessful attempts at irrigation of the clot, biopsy forceps were utilized to fragment the clot. Thereafter, an 8-mm balloon was advanced twice through the clot and inflated to successfully create a lumen. Case 2 and Case 3 include a 53-year old woman (BMI 46) and a 29-year old woman (BMI 43), respectively, who were both admitted for elective RYGB. Both patients experienced persistent nausea for 3 days after surgery. Upper GI series revealed retention of contrast in the gastric pouch, concerning for a gastro-jejunal anastomotic stricture. A subsequent EGD revealed friable, ulcerated, and granulated clot tissue at the gastro-jejunal anastomosis. Thus, a 10-mm gastroscope was passed across the surgical anastomosis to break the clot and relieve the obstruction allowing for passage into the alimenatary limb. Endoscopic dilation has become the elected treatment for gastrojejunal anastomotic stricture after RYGB, due to the low morbidity of this procedure. We highlight three cases of obstructing blood clots at the gastro-jejunal anastomosis managed endoscopically. Endoscopic evaluation and evacuation of clot and fibrinous material should be pursued prior to proceeding straight to laparotomy.

A bidirectional stapling technique for laparoscopic small bowel anastomosis

BackgroundSmall bowel anastomoses can present a technical challenge during laparoscopic procedures, particularly gastric bypass procedures. Early small bowel obstruction (SBO) rates associated with such procedures occur in .7%–5.2% of patients. Herein, we describe how a bidirectional stapling technique moves the enterotomy to the center of the anastomosis, decreasing the chances of an afferent limb obstruction. MethodsA prospectively collected cohort of 2263 consecutive patients who underwent laparoscopic Roux-en-Y gastric bypass with bidirectional stapling of the small bowel anastomosis was evaluated for early SBO. All patients met the National Institutes of Health criteria for bariatric surgery. ResultsOverall, 3 patients’ perioperative courses were complicated by perioperative, early SBO (.13%). These instances were all attributable to intraluminal blood clots and not from inadvertent narrowing of the afferent limb. One was diagnosed on postoperative day 1 by upper gastrointestinal study (UGI); 2 were diagnosed on postoperative day 2 by computed tomography (CT) scan with oral contrast. All 3 patients’ complications were managed with a laparoscopic operation. ConclusionThe bidirectional stapling technique for small bowel anastomoses, with our modifications, is a rapid, well-tolerated, and effective technique that offers potential advantages over standard laparoscopic anastomotic techniques by reducing perioperative SBO complications.

Surgical management of early small bowel obstruction after laparoscopic Roux-en-Y gastric bypass

BackgroundLimited data are available regarding early postoperative small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LRYGB). The aim of the present study was to review our experience with early SBO after LRYGB. The setting was a tertiary referral bariatric center. MethodsWe reviewed a prospectively maintained database to assess the diagnosis, management, and outcomes of patients who underwent surgery for SBO within 30 days of LRYGB. ResultsFrom April 2004 to December 2011, 2126 patients underwent LRYGB. Of these patients, 11 (.5%) required surgical management for early SBO. Of the 11 patients, 9 were women and 2 were men. with a mean age of 53 years (range 35–70) and mean body mass index of 45 kg/m2 (range 38–65). The average interval from LRYGB to the presentation of SBO was 5.0 days (range 2–15). All early SBOs were diagnosed by computed tomography with oral contrast. The causes of early SBO included kinking at the jejunojejunostomy in 4, an intraluminal blood clot near the jejunojejunostomy in 2, angulation of the Roux limb in 1, mesenteric hematoma in 1, intra-abdominal hematoma in 1, obstruction of common channel in 1, and pelvic adhesions from previous surgery in 1. Diagnostic laparoscopy was attempted in all patients. Four patients required conversion to open surgery. Postoperative complications developed in 5 patients; no patient died. Laparoscopic management of early SBO resulted in fewer complications than the open approach. ConclusionEarly SBO after LRYGB is uncommon; however, a prompt diagnosis and surgical intervention are important to prevent additional morbidity. The ability to complete the reoperation laparoscopically varies with the etiology and location of the obstruction.

Blood clot obstruction of the jejunojejunostomy after laparoscopic gastric bypass

BackgroundAcute jejunojejunostomy (JJ) obstruction after laparoscopic gastric bypass secondary to the formation of an intraluminal blood clot is a rare event. We analyzed our experience with such complications from a large consecutive patient series at a university hospital that is a referral center for bariatric surgery. MethodsA retrospective review of patient data in a register of all patients who had undergone gastric bypass from June 2004 to March 2011 was performed. Reoperations were analyzed for the cause and findings. The patients received routine postoperative administration of low-molecular-weight heparin. ResultsOf 1066 patients, 5 (.5%; 4 women and 1 man), who had undergone laparoscopic gastric bypass, with a median body mass index of 42 kg/m2 (range 40–46), underwent reoperation for obstruction of the JJ secondary to a blood clot. The indications for reoperation were signs of bleeding, nausea, or findings on abdominal computed tomography. The time of reoperation was 1, 1, 2, 3, and 11 days after the primary procedure. All patients underwent reoperation by laparoscopy, with evacuation of the blood clot through an opening of the suture or staple lines without additional revision of the JJ. The gastric remnant was decompressed using a percutaneously placed gastrostomy tube. One patient had gastric leakage from the staple lines (blowout) that necessitated several later revisions for subcutaneous abscesses. Another patient developed acute pancreatitis. ConclusionBlood clots can cause early obstruction of the JJ after gastric bypass. Awareness of this potentially rapidly progressive and life-threatening complication will allow immediate intervention and reduce the risk of serious sequelae.

Characterization of Haemorrhagic Enteritis in Dairy Goats and the Effectiveness of Probiotic and Prebiotic Applications in Alleviating Morbidity and Production Losses

The present study aims to investigate whether the disease complex for Haemorrhagic Enteritis (HE) in goats during the winter months is the same as described for Jejunal Haemorrhage Syndrome (JHS) in cattle. The further goal is to determine whether prebiotic and probiotic management strategies developed for JHS in cattle alleviate HE in goats. The clinical, necropsy and microbiologic findings were evaluated for goat cases during a natural HE outbreak. Bacterial pathogens were identified using selective media, biochemical tests, latex agglutination tests and DNA microarray. Feed components were evaluated for mycotoxigenic fungi and mycotoxins. Common clinical signs included stary look, grinding of teeth, an odd twisting of the neck when standing, hind-limb paralysis, rumen stasis, no faecal pellets, profuse drooling and a 50% drop in milk production. A prebiotic/probiotic treatment resolved the symptoms in 14 of 28 goats, but new cases continued to develop. The most common morphologic diagnosis at necropsy was severe jejunitis with intraluminal haemorrhage or blood clots confirming HE. The corn silage contained mycotoxigenic fungi and mycotoxins. There were mixtures of Shiga toxin – producing Escherichia coli (STEC) isolated from the jejunum. The probiotic and prebiotic acted as anti-adhesive agents for STEC colonization in vitro. The prebiotic also acted as a mycotoxin binder in vitro. Removing the mouldy corn silage stopped the mycotoxicosis,but did not correct production losses. Adding a prebiotic or probiotic significantly increased milk production and body condition, but also decreased somatic cell counts. Results confirm that the disease complex for HE in dairy goats consuming mouldy feeds includes mycotoxins and STEC infection. The study also supports the use of prebiotics and probiotics to alleviate the morbidity and production losses associated with the mycotoxicosis.

A study on corroboration between DNA markers (RAPD, ISSR, ITS) and bio-control efficacy of Trichoderma species

The present study aims to investigate whether the disease complex for Haemorrhagic Enteritis (HE) in goats during the winter months is the same as described for Jejunal Haemorrhage Syndrome (JHS) in cattle. The further goal is to determine whether prebiotic and probiotic management strategies developed for JHS in cattle alleviate HE in goats. The clinical, necropsy and microbiologic findings were evaluated for goat cases during a natural HE outbreak. Bacterial pathogens were identified using selective media, biochemical tests, latex agglutination tests and DNA microarray. Feed components were evaluated for mycotoxigenic fungi and mycotoxins. Common clinical signs included stary look, grinding of teeth, an odd twisting of the neck when standing, hind-limb paralysis, rumen stasis, no faecal pellets, profuse drooling and a 50% drop in milk production. A prebiotic/probiotic treatment resolved the symptoms in 14 of 28 goats, but new cases continued to develop. The most common morphologic diagnosis at necropsy was severe jejunitis with intraluminal haemorrhage or blood clots confirming HE. The corn silage contained mycotoxigenic fungi and mycotoxins. There were mixtures of Shiga toxin – producing Escherichia coli (STEC) isolated from the jejunum. The probiotic and prebiotic acted as anti-adhesive agents for STEC colonization in vitro. The prebiotic also acted as a mycotoxin binder in vitro. Removing the mouldy corn silage stopped the mycotoxicosis, but did not correct production losses. Adding a prebiotic or probiotic significantly increased milk production and body condition, but also decreased somatic cell counts. Results confirm that the disease complex for HE in dairy goats consuming mouldy feeds includes mycotoxins and STEC infection. The study also supports the use of prebiotics and probiotics to alleviate the morbidity and production losses associated with the mycotoxicosis.

Extramural Ectopic Ureter in a Domestic Ferret ( Mustela putorius furo)

Ectopic ureter is the most common cause of congenital urinary incontinence in the dog and cat. The occurrence of ectopic ureter in the dog has been estimated to be 0.016%. A 6-month-old ferret was evaluated for urinary incontinence and urine scalding around the perineal and inguinal areas. Ultrasonography showed a nondistended urinary bladder that contained a possible intraluminal blood clot. Excretory urography revealed a left ectopic ureter. The ferret was initially treated with oral amoxicillin-clavulanate and topical silver sulfadiazine ointment for the perineal and inguinal dermatitis associated with the incontinence. Because of the potential for complications and additional surgery with ureteral transplantation, a left nephroureterectomy was performed. Surgical recovery was uneventful and the incontinence improved, although a small amount of incontinence-associated dermatitis was still present 24 days after discharge. Phenylpropanolamine therapy was initiated to address a suspected dysfunction of the urethral sphincter. Urinary incontinence improved with the phenylpropanolamine therapy; however, a small amount of incontinence persisted throughout the 3 months in which the ferret was evaluated. To the authors' knowledge, this is the first report of an ectopic ureter in a domestic ferret.

Diagnosis of bile duct hepatocellular carcinoma thrombus without obvious intrahepatic mass.

To study the diagnosis of hepatocellular carcinoma (HCC) presenting as bile duct tumor thrombus with no detectable intrahepatic mass. Six patients with pathologically proven bile duct HCC thrombi but no intrahepatic mass demonstrated on the preoperative imaging or palpated intrahepatic mass during operative exploration, were collected. Their clinical and imaging data were retrospectively analyzed. The major findings or signs on comprehensive imaging were correlated with the surgical and pathologic findings. Jaundice was the major clinical symptom of the patients. The elevated serum total bilirubin, direct bilirubin and alanine aminotransferase levels were in concordance with obstructive jaundice and the underlying liver disease. Of the 6 patients showing evidence of viral hepatitis, 5 were positive for serum alpha fetoprotein and carbohydrate antigen 19-9, and 1 was positive for serum carcinoembryonic antigen. No patient was correctly diagnosed by ultrasound. The main features of patients on comprehensive imaging were filling defects with cup-shaped ends of the bile duct, with large filling defects presenting as casting moulds in the expanded bile duct, hypervascular intraluminal nodules, debris or blood clots in the bile duct. No obvious circular thickening of the bile duct walls was observed. Even with no detectable intrahepatic tumor, bile duct HCC thrombus should be considered in patients predisposed to HCC, and some imaging signs are indicative of its diagnosis.

Iatrogenic Tracheal Laceration Causing Asphyxia

Endotracheal intubation is a simple, rapid, and safe technique that is being used as a standard procedure for airway management. However, airway injury during endotracheal intubation could be a significant source of morbidity or even mortality for patients and a source of liability for physicians as well. We report an unusual case of fatal tracheal occlusion by intraluminal blood clot complicating endotracheal intubation. The patient, a 62-year-old woman, with renovascular hypertension and incipient renal failure was scheduled for renal autotransplantation. The surgery was uneventful but the postoperative course was complicated with a lethal airway obstruction. At autopsy a linear longitudinal tracheal laceration was identified with an intraluminal blood clot obstructing the tracheal lumen. Tracheal laceration as a cause of death is a rare and potentially fatal complication of endotracheal intubation with intratracheal bleeding, clot formation, tracheal occlusion, and subsequent asphyxia.

Small Bowel Obstruction after Laparoscopic Roux-en-Y Gastric Bypass Caused by an Intraluminal Blood Clot

We report a rare case of acute early postoperative small bowel obstruction after laparoscopic Roux-en-Y gastric bypass due to an intraluminal blood clot at the site of the jejuno-jejunostomy. Patient was treated successfully with enterotomy and removal of the clot. A review of literature showed three similar publications.

Acute, complete proximal small bowel obstruction after laparoscopic gastric bypass due to intraluminal blood clot formation

Background To report the presentation and management of early complete proximal small bowel obstruction from intraluminal clot after laparoscopic Roux-en-Y gastric bypass. Methods We performed a retrospective chart review of 5 female patients who developed small bowel obstruction at the jejunojejunostomy (JJ) secondary to intraluminal clot from January 2001 to January 2003. We analyzed the signs and symptoms, etiology of bowel obstruction, and operative treatment. Results From January 2001 to January 2003, 5 patients who had undergone successful laparoscopic Roux-en-Y gastric bypass developed proximal small bowel obstruction from a solid intraluminal clot secondary to staple line bleeding. All patients were women, with an average age and body mass index of 37 years and 43.41 kg/m 2, respectively. All patients underwent an upper gastrointestinal series on postoperative day 1, which revealed no leak, and all became symptomatic on postoperative day 2. Tachycardia and a “sense of impending doom” were both observed in 80% of the patients with this clinical syndrome. The intraoperative findings consistently revealed intraluminal clot obstructing the JJ. After reexploration and anastomotic revision, all patients had an uneventful recovery, with an average hospital length of stay of 9.8 days (range 8–11). Conclusion Staple line bleeding potentially exacerbated by perioperative subcutaneous heparin use can cause proximal small bowel obstruction at the JJ after laparoscopic Roux-en-Y gastric bypass. It presents on postoperative day 2 most commonly as tachycardia and a “sense of impending doom.” Prompt recognition and immediate reexploration will lead to an uneventful recovery. The need for complete anastomotic JJ revision is discussed.

Life-threatening hemorrhage from enterotomies and anastomoses in 7 horses.

To report our experience with horses that presumptively had severe intraluminal hemorrhage from enterotomy or anastomosis. Clinical study. Six adult horses and 1 adult donkey. A retrospective study was conducted at the University of Illinois (April 1994 to December 2001) to determine the clinical course and outcome of horses with melena and/or anemia and evidence of life-threatening hemorrhage from intestinal incisions. Medical records of all horses that had colic surgery were reviewed to determine the proportion of horses with this complication. In addition, horses that fit the same criteria identified in 3 other veterinary clinics were included. Three horses (1.3%) of those that had enterotomy or anastomosis at the University of Illinois and 4 horses from other clinics had complications presumptively related to severe hemorrhage from these intestinal procedures. Melena became evident within 72 hours of surgery and lasted 12 to 96 hours. Six horses had an acute and severe drop in packed cell volume (PCV), increased heart rates, and other signs of acute hemorrhage, and 1 horse had signs of colic postoperatively. Horses were administered intravenous formalin (3 horses) and whole blood transfusions (4 horses). Repeat celiotomy was performed on 2 horses. In 1 of these horses, a bleeding artery was ligated in the edge of the original enterotomy, and, in the other, a 25-cm-diameter intraluminal blood clot was found occluding the pelvic flexure. A horse that had jejunocolostomy for cecal impaction was not treated for hemorrhagic shock but was euthanatized and necropsied. Necropsy revealed blood-filled bowel from the jejunocolostomy to the anus. One of the remaining 6 horses died of enterocolitis and 5 survived to discharge. Hemorrhage from incisional edges, particularly in the large intestine, should be considered a rare but possibly fatal complication of enterotomy or anastomosis in horses. To prevent fatal hemorrhage from incisional edges during enterotomy or anastomosis, large vessels should be ligated at the original surgery, and hemostatic effects of different closure techniques should be considered. No intraoperative or postoperative findings were useful to predict this complication, and response to supportive medical therapy was favorable.