Introduction

Venous thromboembolism (VTE), manifested as either deep venous thrombosis (DVT) or pulmonary embolism (PE), is an extremely common medical problem, occurring either in isolation or as a complication of other diseases or procedures (1). Cancer is recognized as a major risk factor for venous thromboembolism (2). DVT is an uncommon complication after gastrectomy for gastric carcinoma (3). The incidence is highest in the first few months after diagnosis, which may reflect the biology of the cancer or medical interventions such as major surgery or start of chemotherapy (4).

Case Presentation

Our case was a 67-year-old male. His chief complaints at admission were increases in warmth and diameter of the right upper and lower extremities. His past medical history was significant for an operation held by the Department of General Surgery about 3 weeks ago after investigating the etiology for obstructive jaundice. He underwent cholecystectomy + gastroenterostomy + choledochojejunostomy + Braun anastomosis and a wedge biopsy of the liver. Histopathological examination revealed adenocarcinoma at the duedonal papilla and adenocarcinoma of the liver with chronic cholecystitis (Figures 1&2).

Figure 1

Figure 1

Figure 2

Figure 2

His physical examination showed findings consistent with DVT of the right upper and lower extremities. Color Doppler ultrasound examination of the venous systems of the extremities was done. It defined that right popliteal vein was filled with thrombus which extended into the crural veins. Moreover, this vein was incompressible with ultrasound probe with no flow within the lumen of the popliteal and crural veins (Figures 3&4).

Figure 3

Figure 3

Figure 4

Figure 4

Again, the same investigation identified that the axillary vein was filled with thrombus which extended proximally into subclavian vein and distally into the brachial vein. It extended even into cephalic and basilic veins. The aforementioned veins did not have any flow with color and spectral analyses (Figures 5&6).

Figure 5

Figure 5

Figure 6

Figure 6

Our patient was then hospitalized and we started to apply our medical treatment strategy. Continuous infusion of the unfractioned heparin was introduced to keep the activated clotting time (ACT) between 200 to 250 seconds. Moreover, her affected arm was elevated. Complementary medical treatment included an oral preparation of “Diosmin 450 mg + Hesperidin 50 mg”( 2 tablets each morning), enteric coated tablet of 300 mg acetylsalicylic acid per day, heparinoid(luitpold) 445 mg/100 g gel 2x1 US and a non-steroidal anti-inflammatory drug preparation orally. He has been hospitalized for 5 days. He was kept under low-molecular-weight heparin(tinzaparin sodium SC) anticoagulation therapy for 3 months. He is asymptomatic and his control color Doppler ultrasound showed no recurrence or post-thrombotic sequelae.

Discussion

Patients with cancer make up approximately 20% of those presenting with first time VTE, and the presence of VTE forebodes a much poorer prognosis for patients with cancer, likely because of the morbidity associated with VTE itself and because VTE may herald a more aggressive cancer (1). Several recent studies have shown that the incidence of VTE is highest in patients who present with metastatic cancer, particularly cancers associated with a high one-year mortality rate, such as pancreatic cancer. The incidence rate of VTE is highest in the first few months after the diagnosis of cancer, and it decreases over time thereafter. For most cancers, it is not clear to what extent undergoing major surgery adds to the already high risk of VTE associated with the presence of the cancer (2).

In the study of Alcalay et al.; they analyzed 68,142 colorectal cancer patients and approximately 70% underwent a major operation. The 2-year cumulative incidence of VTE was 2,100 patients (3.1%), with an incidence rate that decreased significantly over time from 5.0% (events/100 patient-years) in months 0 to 6 to 1.4% during months 7 to 12 to 0.6% during the second year. The risk of VTE was significantly reduced among patients who underwent an abdominal operation. In risk-adjusted models, VTE was a significant predictor of death within 1 year of cancer. The incidence of VTE among colorectal cancer patients was highest in the first 6 months after diagnosis and decreased rapidly thereafter. Metastatic disease and the number of medical comorbidities were the strongest predictors of VTE (5).

Patients with a diagnosis of acute deep venous thrombosis have traditionally been hospitalized and treated with unfractionated heparin followed by oral anticoagulation therapy. Several clinical trials have shown that low-molecular-weight heparin is at least as safe and effective as unfractionated heparin in the treatment of uncomplicated deep venous thrombosis (6). Recent evidence indicates that low-molecular weight heparins (LMWHs) improve survival in patients with advanced cancer through mechanisms beyond their effect as anticoagulants (1). Advantages include a decreased incidence of heparin-induced thrombocytopenia and fewer episodes of bleeding complications (6). Because of their improved efficacy and safety and potential anti-neoplastic effect, the LMWHs have become the anticoagulants of choice for treating VTE associated with cancer (1). Recent studies demonstrate that home therapy of DVT with LMWH, compared with inpatient therapy with unfractionated heparin, produces comparable clinical outcomes and patient satisfaction, with dramatic cost savings (7).