Gastro Case Challenge: After Routine Procedure, 52-Year-Old Has Black Vomit, Diarrhea

Sarah El-Nakeep, MD


February 27, 2023

CT with angiography of the abdomen showed a complete occlusion of the mesenteric vessels and celiac trunk, with partial extension of the thrombus into the aorta (Figures 5 and 6). In addition, CT demonstrated patches of acute bowel ischemia in the form of absent perfusion of the bowel loops, with maintained thickness, and the absence of superimposed infection with pneumatosis cystoides coli (Figures 7 and 8).

Figure 5.

Figure 6.

Figure 7.

Figure 8.

The bowel ulcerations, edema, and necrosis apparent on CT present in three stages:

  • Stage I, which affects the mucosa only and is reversible

  • Stage II, which affects the submucosa and muscularis propria

  • Stage III, which is transmural

Superimposed infections on the necrotic tissue may cause bowel perforation or pneumoperitoneum from pneumatosis cystoides coli.[2]

Cases of mesenteric ischemia have been reported after both open and laparoscopic cholecystectomy. Most of the cases with extensive bowel necrosis resulted in the death of the patient.[5,6,7]

The patient in this case underwent laparoscopic cholecystectomy 2 weeks after ERCP. The recommended timing of elective laparoscopic cholecystectomy after clearing the cause of biliary obstruction is within 6 weeks of ERCP.[8] A trial that examined the timing of early cholecystectomy after ERCP found that the operation should be performed at least 6 days after ERCP. The timing is explained by the subacute inflammation that starts after 3 days; the tissues are edematous and are not suitable for operating until the edema resolves by day 6.[9]

Although mesenteric ischemia after laparoscopic cholecystectomy is a rare complication, it has a devastating outcome. This complication is usually associated with cardiovascular disease or a hypercoagulable state. The patient's normal D-dimer and FDP levels ruled out disseminated intravascular coagulation.

Armand Trousseau, a French physician, explained the concept of migratory venous thrombosis associated with cancer in 1865. Pancreatic cancer is known to cause a state of hypercoagulability, which results in arterial or venous thrombosis. Venous thrombosis is more common in pancreatic cancer than in other cancers, reaching a prevalence of 60% in autopsy studies.[10] In the patient in this case, ERCP and MRCP showed no signs of pancreatic focal lesions. In addition, her cancer antigen 19-9 level was normal.

COVID-19 and vaccination are associated with a hypercoagulable state. Immune thrombotic thrombocytopenia induced by COVID-19 vaccination has been reported with AstraZeneca, Moderna, and Pfizer-BioNTech vaccines.[11] In this patient, however, the platelet count was normal.

Celiac artery thrombosis could elicit symptoms similar to those of severe peptic ulcer disease, such as epigastric pain and vomiting, which this patient experienced. Complete celiac artery occlusion is uncommon; however, partial occlusion of individual mesenteric vessels (up to 50%) is noted in 6%-10% of autopsies in the general population.[12]

Acute secondary ascending cholangitis could complicate a cholecystectomy. Bacterial infection in obstructed bile or hepatic ducts causes ascending cholangitis, and the diagnosis is established by clinical, laboratory, and radiologic findings. In this case, the patient's bilirubin and ALP levels were within normal limits, which indicated no biliary obstruction.[13,14] Post-ERCP acute cholangitis is present in 1%-5% of patients who undergo the procedure. Ascending cholangitis could occur after laparoscopic cholecystectomy if exploration of the bile duct was performed with either a transcystic or a transductal approach.[15]

This patient did not have an intestinal obstruction. She was able to pass food and flatus, and the erect and supine radiographs did not show a fluid level.


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