Introduction

An intestinal obstruction due to intraluminal blood clots is a postoperative complication that is infrequently reported in literature. We reported the case of a patient with an intestinal obstruction due to postoperative intraluminal blood clots from a Roux-en-Y hepaticojejunostomy. Clinical Case: A 53-year-old male patient appeared with recurring cholangitis secondary to a benign stenosis of the bile duct after a laparoscopic cholecystectomy performed 2 years prior. Treatment with an endoprosthesis by endoscopic retrograde cholangiopancreatography (ERCP) did not improve cholangitis episodes, for which reason transition to reconstruction by hepaticojejunostomy was considered. He showed signs of intestinal obstruction during early postoperative care. The Computed Tomography (CT) scan of the abdomen with contrast showed free fluid and signs of obstruction. The patient was taken to an emergency surgery, where the Roux-en-Y anastomosis was found to be obstructed by a large intraluminal blood clot. It required an enterotomy to be extracted. Discussion: A postoperative intestinal obstruction secondary to intraluminal blood clots is unusual, but must be suspected in patients with symptoms of intestinal obstruction. The ideal method for diagnosis is by tomography and treatment involves a relaparotomy to extract the blood clots. It is important for doctors to have knowledge of this condition, since it is a rare complication that requires good diagnostic insight and timely treatment. Palavras-chave: Thrombose; Small intestine; Intestinal Obstruction; Gastrectomy; Post-operative period. Intestinal obstruction due to intraluminal clot is a rare postoperative complication reported in the literature, among its causes is Roux Y, which has been widely used in procedures such as gastrectomy for cancer, gastric bypass for obesity and in hepaticojejunostomy or choledochojejunostomy as an end-to-end anastomosis [1]. Complication rates for Roux-en-Y hepaticojejunostomy are relatively low in large series [2,3] but are of important consideration to the surgeon, as this is a complication in which prompt repair is required.

The prevalence of intestinal obstruction due to postoperative clots in hepaticojejunostomy is not known in the world and similar cases have not been reported in Colombia; However, the main cause of intestinal obstruction due to postoperative clots occurs in laparoscopic gastric bypass surgery and has an average presentation time of 15 days, with an approximate range of 5 to 15 days [4]. The different etiologies that generate intestinal obstruction after gastric bypass surgery include: non-compliance with diet in 46%, anastomotic edema in 23%, narrowing of the jejunostomy in 23% and intraluminal clots in 8% [4,5]. In hepaticojejunostomy, the main complications are intestinal obstruction (adhesion and intussusception), which represents 4.5% of complications, and approximately 4% of patients report pancreatitis or ascending cholangitis [3]. This is a very rare entity without reports at the national level, probably due to underreporting; however, it is highly suspicious for the diagnosis, since, in the event of this complication, rapid confirmation by images (mainly tomography) and timely treatment are necessary. As a goal, the formation of intraluminal clots that cause intestinal obstruction should be included in the differential diagnosis when faced with similar clinical findings in the immediate postoperative period after a hepaticojejunostomy, so it is important, for the surgeon and the general practitioner, the knowledge of this complication. We report the case of a patient with intestinal obstruction due to postoperative intraluminal hematoma of a Roux-Y hepaticojejunostomy. A 53-year-old male patient with a history of type 2 diabetes mellitus, arterial hypertension, grade III hepatic steatosis, stage V acute renal failure that required hemodialysis. In 2017, an open cholecystectomy was performed due to choledocholithiasis, which could not be resolved by ERCP; secondary to this, he presented recurrent cholangitis, which was managed one year later with ERCP endoprosthesis, presenting recurrence in episodes of cholangitis, for which no improvement was found.

It presents with a clinical picture of 10 days of evolution, consisting of abdominal pain in the epigastrium, generalized itching, fever of 38.5°, for which it is considered a diagnosis of cholangitis and antibiotic management is started. On physical examination, he was jaundiced, with pain on abdominal palpation and no signs of peritoneal irritation. A cholangioresonance was performed, which showed severe dilation of the extrahepatic bile duct and the Wirsung duct with the presence of stones inside; therefore, it was decided to perform reconstruction of the bile duct. It was decided to reconstruct the bile duct with Roux-Y with transmesocolic end-to-side hepatojejunal anastomosis, lateral lateral intestinal anastomosis and a subhepatic nelaton drain was installed, without intra-surgical complications, or in the immediate postoperative period. On the second postoperative day, he presented significant hematemesis without alteration of vital signs, so it was decided to suspend enoxaparin and start an omeprazole drip. Subsequently, the hemoglobin drops to 8 g / dl, for which 2 units of blood cell concentrate are transfused. The next day, the hemoglobin rises to 9 g/dl without improvement in the condition.

The patient continues with abdominal pain and worsening of his general condition, a contrasted abdominal Computed Tomography (CT) is performed, which reveals signs of intestinal obstruction and free fluid, with occupation of the proximal intestine, for which he is taken to relaparotomy. An obstruction of the proximal small intestine is found secondary to tamponade by abundant clots at the level of the Roux-Y, a distal enterotomy is performed and 250 cc of intraluminal clots are extracted (Figure 1), the Roux-Y is reinforced in its anterior part, He installed an anterior drain close to the pylorus in case of rebleeding, the drain was extracted to the right flank, a 1-liter bag was left and transferred to the ICU. The patient evolves towards improvement, so he is transferred to hospital after 3 days and later.

When intestinal obstruction due to intraluminal clots occurs, hematemesis is a cardinal sign; Furthermore, it is important to regularly check the hemoglobin levels, as anemia is generated by intestinal bleeding [6]. Which must be replaced with hemoconcentrates if necessary, as was done in the patient. The use of computed tomography for patients with this clinical presentation has been the diagnostic method of choice [7]; in addition, computed tomography can provide important information on the cause and position of the obstruction and rule out other possible early postoperative complications [8]. Obstruction resulting from intraluminal blood clot formation in the small intestine is caused by inadequate hemostasis in the stapled anastomosis, inadequate verification of the anastomoses, or as a cause of undiagnosed pre-existing disease, such as a clotting disorder and it is rarely seen in the immediate postoperative period [9]. In this case, adequate hemostasis was verified and the anastomosis was verified. Regarding comorbidities, in grade 3 hepatic steatosis that the patient presented, there is still no liver dysfunction that could explain any deficit in coagulation factors; However, the patient’s chronic kidney failure, for which he required dialysis, may be the cause of coagulation dysfunction, which could have contributed to the complication presented.

The principles of the technique in hepaticojejunostomy that minimize the possibilities of complications include the low tension, the anastomosis should Start by being as large as possible and there should be complete apposition of the bile duct lining to the jejunal mucosa. Another important cause of obstruction as a differential diagnosis is intramural hematoma, which presents similar symptoms with a postoperative time similar to that of intraluminal clots; the first report of intramural hematoma in man was in 1838 by McLaughlan [10]. Cases of intestinal obstruction due to intramural hematoma and intraluminal clots have been described, mainly in trauma [11,12], laparoscopic gastric bypass with Y-de-Roux (8) [13-17], spontaneous obstruction as in the case of a child with 8 years [18], hemophilia [19], anticoagulant treatments [20-24] and as a complication of endoscopy [25]. Table 1 describes the cases of intraluminal clots with their causes.

Source

Own elaboration. In general, an intramural hematoma is spontaneously reabsorbed in 14 to 90 days [26]. So surgical intervention is rarely necessary; therefore, the treatment for intramural hematoma is non-surgical [27]. Because most of these hematomas resolve spontaneously, surgical management is rare [28]. On the contrary, the recommended treatment for a postoperative intraluminal clot intestinal obstruction is done, [29,30]. Either by suctioning or removing the clot by laparoscopy by opening the cavity, or by endoscopy. However, the most widely used surgical method for evacuation of hematomas is laparoscopic or open drainage [31]. Laparoscopic emergency reoperation with enterotomy is the most recommended to avoid greater morbidity or mortality [9].

Conclusion

Intestinal obstruction due to intraluminal clots is a very rare complication of Roux-Y hepaticojejunostomy. However, it is important for the doctor to be aware of this postoperative complication, since a timely diagnosis is needed based on symptoms such as hematemesis and severe crampy abdominal pain. With this, the diagnosis must be confirmed with an abdominal tomography to be taken to surgery for enterotomy with correction of the anastomosis, if necessary.

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