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Endgames Case Report

Multiple emboli after gastrectomy

BMJ 2010; 340 doi: (Published 05 May 2010) Cite this as: BMJ 2010;340:c1663
  1. Matthew Rogers, core medical trainee year 2,
  2. Graham Smith, consultant haematologist
  1. 1Department of Haematology, Frimley Park Hospital, Surrey GU16 7UJ
  1. matthewjohnrogers{at}

    A 60 year old man underwent a total gastrectomy for T2a, N0, M0 gastric cancer. Seven days after the operation, while still recovering in hospital, he developed left lower leg pain of sudden onset. He described the pain as severe and said that his leg below the knee felt cold and numb.

    His medical history included one deep vein thrombosis and one pulmonary embolus several years apart. He had no other medical history of note. In particular, he had no history of peripheral vascular disease or intermittent claudication. Before the gastrectomy, the only drug that he was taking was long term warfarin; this had been changed to therapeutic dose low molecular weight heparin perioperatively, and he remained on heparin at the onset of leg pain. He was an ex-smoker.

    On examination he seemed to be in pain, with a regular pulse of 100 beats/min, blood pressure of 140/70 mm Hg, and temperature of 36.5°C. His left leg was cold and pale, with no pulses palpable below the thigh. The rest of the cardiovascular examination was normal. Computed tomography angiography showed abrupt occlusion of the left common femoral artery, with a further occlusion of the left popliteal artery.

    Blood tests were as follows: haemoglobin 99 g/l, white blood cell count 17.7×109/l, platelets 65×109/l, urea 4.7 mmol/l; creatinine 68 µmol/l, bilirubin 12 µmol/l, activated partial thromboplastin time 27.7 seconds (normal range 26-36), and prothrombin time 14.4 seconds (normal range 11-26). Three days before the onset of leg pain his blood results had been: haemoglobin 101 g/l, white blood cell count 17.6×109/l, and platelets 163×109/l.

    An embolectomy was performed. Two days later he developed left subchondral and pleuritic chest pain. Oxygen saturation fell to 92% on air. Respiratory examination was otherwise unremarkable; examination of the …

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