This is a 53-year-old obese male with severe obstructive sleep apnea syndrome, smoker of 2 packs a day and habitual drinker (160 g/day).
She had a history of surgery only one right ankle fracture and bilateral cataract.
She did not take medication regularly.
The patient consulted in two occasions in the emergency department due to diffuse acute abdominal pain and fever and was discharged on the first occasion because the complementary tests were normal.
On the second occasion, the clinical evolution was already 5 days and the patient came to the hospital due to persistent symptoms.
Physical examination revealed obesity and mild malar telangiectasias.
He was hypertensive, without tachycardia, eupneic at rest, although with global hypoventilation, with no signs of encephalopathy and affinement at the time of examination.
The abdomen was very globulous, distended, tympanic with pain at palpation diffusely, generalized defense, absence of noise and mild collateral circulation.
No signs of deep venous thrombosis in limbs were observed.
Blood glucose 214 mg/dl, albumin 2.91 g/dl, total bilirubin 1.60 mg/dl, normal AST/PTG, normal AF with GGT 186 U/l, and normal serum ferritin values 186 U/l.
Renal function and lipid profile were normal.
Normal tumor markers.
Normal homocysteine.
HBV and C serology were negative.
The initial hematocrit and the prothrombin index were 48%, 114,000/ul, leukocytosis 21.
The hemocultives were infected with feverish peaks.
Antiphospholipid antibodies: negative.
Thrombophilia study: mild deficiency of antithrombin III 68%-120) and functional C protein 56% (70-140) and had heterozygous mutation of the factor II gene 20210.
The scan showed a zyrotic liver with ascites, thrombosis of the superior mesenteric vein and portal vein with thickened loops.
Initially, medical treatment with anticoagulants, empirical antibiotic therapy (piperacillin-tazodone), and supportive treatment were decided, evolving torpidly.
The analysis of ascitic fluid is compatible with data of secondary bacterial peritonitis with polymicrobial culture for E. Coli and Enterococcus faecium, so that antibiotic therapy is adjusted according to the antibiogram and a new intestinal evidence is repeated.
Water phase reactants are normalized, responds favorably to diuretics but persists with a febricula maintained without sepsis criteria.
Episodes of clinical and etiological discordance and data on intestinal distress were obtained. Emergency surgery was performed with the objective of finding a plastron with irreversible ileocecal resection loop and perforation in the proximal ileum and venous thrombosis with terminal ileum.
The pathology report confirmed transmural necrosis with perforation and peritonitis of the resected intestinal segments.
The postoperative period was uneventful except for surgical wound infection, which slightly prolonged hospital stay.
The patient is currently under treatment with oral anticoagulation and asymptomatic from the digestive point of view, pending to check by radiology whether or not the repermeabilization of the portomesenteric axis has been achieved.
