[A case of ulcerative colitis complicated by disseminated intravascular coagulation that improved markedly after surgery].

A 57-year-old man presenting with severe ulcerative colitis (UC) complicated by disseminated intravascular coagulation (DIC) was referred to our hospital. Since it was difficult to improve DIC immediately with any medical treatment, total proctocolectomy, ileoanal canal anastomosis, and ileostomy were performed on the patient. Soon after the surgery, his platelet count and coagulability improved, and he recovered from DIC. Thus, when the cause of DIC is probably UC itself, and medical treatment has limited efficacy in improving the DIC, surgery should be performed as soon as possible to eliminate the cause of DIC, considering the general condition of the patient.

Successful repeated uterine artery embolization in postpartum hemorrhage with disseminated intravascular coagulation: a case report and literature review.

BACKGROUND: Postpartum hemorrhage (PPH) is a potentially fatal condition requiring urgent and appropriate intervention. Uterine artery embolization (UAE) has a high hemostatic capacity for PPH, but it may fail. Disseminated intravascular coagulation (DIC) has been reported as a risk factor associated with the failure of UAE. CASE PRESENTATION: A 37-year-old primigravida with dichorionic diamniotic twins and placenta previa underwent cesarean section. The blood loss during surgery was 4950 mL. Hemostasis was achieved using an intrauterine balloon tamponade device. However, she lost a further 2400 mL of blood 5 h after surgery. We embolized both uterine arteries using gelatin sponges and confirmed hemostasis. She was suffering from DIC and received ample blood transfusions. However, a further 1300 mL of blood was lost 18 h after surgery and we performed repeated UAE, with complete recanalization of the uterine arteries on both sides and re-embolization with gelatin sponges. Her DIC was treated successfully by blood transfusions at this time, and she showed no further bleeding after the repeated UAE. CONCLUSIONS: DIC is a risk factor for the failure of UAE. Repeated UAE may be effective after sufficient improvement of the hematological status in patients with PPH and DIC.

Dramatic response of acute disseminated intravascular coagulation to erlotinib in a patient with lung adenocarcinoma with activating EGFR mutation.

Disseminated intravascular coagulation (DIC) is a commonly encountered clinical situation characterized by thrombotic occlusion or bleeding in patients with lung cancer. DIC in patients with cancer is usually asymptomatic, taking a chronic form as a compensatory mechanism. Although acute DIC in patients with lung cancer is rarely reported, it can be fatal. We herein describe a patient with lung adenocarcinoma with an activating mutation of the epidermal growth factor receptor (EGFR) gene who developed acute DIC after minor surgical excision. The patient's condition dramatically improved immediately after administration of erlotinib. This report alerts physicians to the occurrence of acute DIC and serves as a reference in treating EGFR mutation-positive lung cancer in patients with DIC.

Neonatal Compartment Syndrome Associated With Disseminated Intravascular Coagulation.

Neonatal compartment syndrome is a rare, but devastating limb-threatening condition that requires early recognition and timely surgical intervention. We discuss the clinical presentation and management challenges of a neonate with forearm compartment syndrome and disseminated intravascular coagulation.

Hand-assisted laparoscopic splenectomy for sclerosing angiomatoid nodular transformation of the spleen complicated by chronic disseminated intravascular coagulation: a case report.

A 36-year-old man who presented with a nosebleed and anemia was referred to our hospital. Laboratory test results showed platelet depletion, decreased levels of fibrinogen, and increased fibrinogen degeneration products. CT showed a 13-cm splenic tumor. T2 -weighted MRI revealed a high-intensity mass. We preoperatively diagnosed splenic hemangioma with chronic disseminated intravascular coagulation and scheduled an operation to relieve the disseminated intravascular coagulation. We also performed hand-assisted laparoscopic splenectomy to ensure easy handling of the splenomegaly. The resected specimen microscopically consisted of hemorrhages and hemangiomatous lesions, and multiple angiomatoid nodules were scattered and separated by fibrocollagenous stroma with inflammatory cells. Three types of vessels (capillaries, sinusoids and small veins) were contained in the angiomatoid nodules, and the pathological diagnosis was sclerosing angiomatoid nodular transformation. The results of this case suggest that we should consider sclerosing angiomatoid nodular transformation in the differential diagnosis of patients with splenic tumors, as sclerosing angiomatoid nodular transformation with hemangiomatous features may cause coagulation disorders for which splenectomy should be performed.

Operative and nonoperative management of chronic disseminated intravascular coagulation due to persistent aortic endoleak.

Disseminated intravascular coagulation (DIC) due to endoleak is a rare complication following endovascular aneurysm repair. Two of the four previously reported cases occurred in patients with cirrhosis. We describe three patients with normal liver function who developed DIC due to delayed high-flow (type Ia or III) endoleaks. Two patients underwent successful surgical repair, and the third was managed medically. All three patients had chronic thrombocytopenia prior to developing an endoleak as did the four reported cases in the literature. We propose that thrombocytopenia, like cirrhosis, be considered a risk factor for DIC due to endoleaks in patients undergoing endovascular aneurysm repair.

Early coagulopathy in patients with ruptured abdominal aortic aneurysm.

Ruptured abdominal aortic aneurysm (AAA) is associated with a high mortality despite surgical management. Earlier reports indicate that a major cause of immediate intraoperative death in patients with ruptured AAA is related to hemorrhage due to coagulopathy. Acidosis is, besides hypothermia and hemodilution, a possible cause of coagulopathy. The aim of the present study was to investigate the incidence of coagulopathy and acidosis preoperatively in patients with ruptured AAA in relation to the clinical outcome with special regard to the influence of shock. For this purpose, 95 consecutive patients who underwent surgery for AAA (43 ruptured with shock, 12 ruptured without shock, and 40 nonruptured) were included. Coagulopathy was defined as prothrombin time (international normalized ratio [INR]) ≥1.5 and acidosis was defined as base deficit ≥6 mmol/L. Mortality and postoperative complications were recorded. The present study shows a state of acidosis at the start of surgery in 30 of 55 patients with ruptured AAA. However, only in 7 of 55 patients with ruptured AAA a state of preoperative coagulopathy was demonstrated. Furthermore, in our patients with shock due to ruptured AAA only 2 of 12 deaths were due to coagulopathy and bleeding. Indeed, our results show a relatively high incidence of thrombosis-related causes of death in patients with ruptured AAA, indicating a relation to an activated coagulation in these patients. These findings indicate that modern emergency management of ruptured AAA has improved in the attempt to prevent fatal coagulopathy.

Subtotal splenic embolization is a safe and effective treatment for isolated splenic vascular tumors associated with consumptive coagulopathy.

Consumptive coagulopathy is a known complication of large vascular tumors. We describe 2 episodes of consumptive coagulopathy in young children, which were secondary to isolated splenic vascular tumors. One child was successfully treated by subtotal embolization of the spleen, whereas the second child required splenectomy after an initial embolization improved--but did not fully control--his consumptive coagulopathy.

Parathyroid adenoma with hypertensive crisis and intracerebral hemorrhage mimicking hemolysis, elevated liver enzymes, low platelets syndrome.

BACKGROUND: Hyperparathyroidism is seldom encountered during pregnancy. Moreover, when the disease does occur, it is typically masked until late pregnancy or after delivery. CASE: A previously healthy multiparous woman presented with sudden-onset severe preeclampsia with hemolysis, elevated liver enzymes, low platelets syndrome at 37 weeks of gestation. Acute intracerebral hemorrhage and disseminated intravascular coagulapathy developed 24 hours after cesarean delivery and persisted after craniotomy. Hypercalcemia and hyperparathyroidism were noted, and imaging studies revealed parathyroid tumor. The patient recovered from severe preeclampsia after resection of a hemorrhagic parathyroid adenoma and was fully rehabilitated after 3 months. CONCLUSION: This patient exhibited a concealed hyperparathyroidism with acute hypertensive crisis, probably attributable to hemorrhagic parathyroid adenoma. The presentation mimics acute late-onset preeclampsia and requires vigilant diagnosis followed by surgery.

Intestinal ischemia/reperfusion: microcirculatory pathology and functional consequences.

BACKGROUND: Intestinal ischemia and reperfusion (I/R) is a challenging and life-threatening clinical problem with diverse causes. The delay in diagnosis and treatment contributes to the continued high in-hospital mortality rate. RESULTS: Experimental research during the last decades could demonstrate that microcirculatory dysfunctions are determinants for the manifestation and propagation of intestinal I/R injury. Key features are nutritive perfusion failure, inflammatory cell response, mediator surge and breakdown of the epithelial barrier function with bacterial translocation, and development of a systemic inflammatory response. This review provides novel insight into the basic mechanisms of damaged intestinal microcirculation and covers therapeutic targets to attenuate intestinal I/R injury. CONCLUSION: The opportunity now exists to apply this insight into the translation of experimental data to clinical trial-based research. Understanding the basic events triggered by intestinal I/R may offer new diagnostic and therapeutic options in order to achieve improved outcome of patients with intestinal I/R injury.

Kasabach-Merritt syndrome: case reports of successful treatment with partial tumor resection and vincristine chemotherapy.

Kasabach-Merritt syndrome is a life-threatening and localized consumption coagulopathy, characterized with profound thrombocytopenia and microangiopathic anemia. The huge tumor is the major cause of rapid platelet destruction, so we supposed the reduction of tumor size could reduce the platelet destruction and improve the clinical condition. In our cases, the vascular tumor occupied one of the extremities, or the head or face. However, removal of the whole tumor would have resulted in the amputation of this extremity or the destruction of the face, and partial tumor removal was suitable. The wound could be repaired with skin graft. Vincristine chemotherapy after the operation was necessary to prevent the enlargement of the remaining tumor. Two cases which were ineffectively treated by other means were treated in this way.

Disseminated intravascular coagulation after endovascular aneurysm repair: resolution after aortic banding.

Disseminated intravascular coagulation (DIC) has been shown to affect 2% to 4% of patients with abdominal aortic aneurysms. In rare cases of DIC caused by aneurysms, operative repair has been curative. Endovascular aneurysm repair (EVAR) has been established as an effective treatment. We report a 73-year-old man in whom severe bleeding developed from groin incisions and cannulae sites immediately after EVAR. An intraoperative angiogram showed a type I endoleak, but the procedure had to be abandoned due to continued bleeding. Blood tests confirmed a diagnosis of disseminated intravascular coagulation that persisted chronically 3 months postoperatively. Attempts to repair the endoleak with stenting were unsuccessful, resulting in persistence of disseminated intravascular coagulation. This resolved after successful treatment of the endoleak with aortic banding.

Aortic aneurysm-induced disseminated intravascular coagulopathy: successful surgical repair.

Aortic aneurysm is a rare cause of disseminated intravascular coagulopathy (DIC). We present the developmental course of DIC in a 70-year-old male patient who had a thoracoabdominal aortic aneurysm characterized by a progressive descending aortic aneurysm presenting as subcutaneous hemorrhage of acute onset. He was diagnosed as having aortic aneurysm-induced DIC. After adequate infusion of blood components, surgical repair of the descending aortic aneurysm was carried out successfully. The patient's bleeding tendency stopped dramatically in the early postoperative period as identified by clinical and laboratory findings. We concluded that the occurrence of DIC was due mainly to the progressive descending aortic aneurysm in the present patient and that surgical repair could be the definitive treatment of DIC in this setting.

[A case of disseminated bone marrow carcinosis with disseminated intravascular coagulation successfully controlled with S-1 after total gastrectomy for advanced gastric cancer].

Bone marrow carcinosis due to gastric cancer with disseminated intravascular coagulation(DIC)occurs suddenly, progresses rapidly, and has a very poor prognosis. In addition, physical status tends to be bad at the time of the episode, and palliative care is generally selected as the treatment method. The case was a 70-year-old woman who underwent total gastrectomy for scirrhous stomach cancer five years previously. She recently noticed gingival hemorrhage, and was referred to our hospital by a nearby doctor. As a result of her examination, she was diagnosed with disseminated bone marrow carcinosis as a postoperative recurrence of gastric cancer that resulted in DIC. We transfused blood platelets and fresh frozen plasma into her, and controlled the bleeding tendency temporarily. She was started on oral administration of S-1 for improvement of DIC, and the therapy was successful without loss of QOL. It is easy to continue S-1 therapy as chemotherapy in the outpatient department, because it is a matter of internal medicine.

Polytrauma--pathophysiology and management principles.

BACKGROUND: Multiple injury results in a complex pathophysiological and immunological response. Depending on the individual injury pattern, the time elapsed after injury, and the systemic "danger response", the surgical treatment has to be modified. OBJECTIVES: This overview provides new insights in the pathophysiology of the early danger response after polytrauma and outlines the main resulting consequences for surgical management. RESULTS: First, synchronically to the clinical assessment, life-saving procedures need to be performed rapidly, such as control of massive intra-thoracic or abdominal bleeding and decompression of the chest and brain, as standardized by advanced trauma life support guidelines. During the second phase of "day-one-surgery" damage-control interventions such as debridement, decompression and temporary fracture stabilization are needed to avoid an excessive molecular and cellular danger response. Trauma-adjusted surgical techniques are crucial to limit the systemic response known to put remote organs at risk. In the "vulnerable phase" when the patient's defense is rather uncontrolled, only "second look" debridement to minimize a "second hit" is recommended. After stabilization of the patient as indicated by improvement of tissue oxygenation, coagulation, and decreased inflammatory mediators, "reconstructive surgery" can be applied. CONCLUSION: Individually adjusted surgical "damage control" and "immune control" are important interactive concepts in polytrauma management.

Deteriorating consumptive coagulopathy with type III endoleak following endovascular repair for abdominal aortic aneurysm associated with liver cirrhosis.

PURPOSE: To report a case of deteriorating consumptive coagulopathy with type III endoleak following endovascular aneurysm repair (EVAR) of the abdominal aorta associated with liver cirrhosis. CASE REPORT: A 72-year-old man with liver cirrhosis developed type III endoleak following EVAR. Spontaneous intramuscular hematoma developed due to deteriorating consumptive coagulopathy induced by type III endoleak and liver dysfunction. Although additional EVAR was performed at 52 months after primary EVAR, the patient died due to multiorgan failure and multifocal hematoma of the muscles and subserosa. CONCLUSION: EVAR for patients with liver dysfunction and coagulopathy should be considered with great caution. We suggest that prompt and adequate treatment using an endovascular technique or surgical repair should be performed for patients with liver dysfunction, coagulopathy, and turbulent endoleak, even if the coagulopathies are worse compared to before EVAR.

Disseminated intravascular coagulopathy caused by intracardiac mesothelioma.

We report a case of intracardiac mesothelioma complicated by chronic disseminated intravascular coagulopathy in a 50-year-old woman. Her symptoms were completely relieved by emergency resection of the tumor. Primary resection of the intracardiac mesothelioma is adequate treatment for this complicated surgical problem.

Disseminated intravascular coagulopathy: manifestations after a routine dental extraction.

Clinical signs and symptoms of acute disseminated intravascular coagulopathy (DIC) include bleeding from body orifices, such as the nose, mouth, or ear, bleeding from an intravenous (IV) site, areas of ecchymosis, or blood in the urine or stool. The underlying disease triggering DIC usually determines the clinical presentation. However, patients with chronic DIC (compensated DIC) may possess subclinical signs and symptoms, and the bleeding disorder may only be identified through laboratory findings. In this compensated form, the triggering factor is exposed slowly and in small amounts (seen in malignancies and vasculitis), allowing replenishing of the augmented factors by the liver, adequate reticuloendothelial clearance of fibrin degradation products, and increased production of platelets, which prevent secondary fibrinolysis and the signs of bleeding. 1,4 We report a case of an 82-year-old male who presented to the emergency room 24 hours after a routine dental extraction with bleeding from the tooth socket, severe hypotension, and presence of ecchymosis on his chest. Clinical and radiographic exam revealed multiple thoracic and abdominal aortic aneurysms, as well as infrarenal and iliac aneurysms, continuous oral hemorrhage, and a unique presentation rarely documented in the literature: a bleeding tooth socket as the initial clinical sign and presentation of DIC.

Acute renal failure and disseminated intravascular coagulation following an idiosyncratic reaction to Alemtuzumab (Campath 1H) or fludarabine.

Alemtuzumab (Campath 1H) is a recombinant DNA derived humanized monoclonal antibody which targets CD52 antigens on B and T cells. It is increasingly used as a conditioning agent for bone marrow transplantation. We describe the case of a 37 year old woman who developed acute renal failure and disseminated intravascular coagulation (DIC) following one dose of Campath and Fludarabine. Campath was thought to be the most likely causal agent although Fludarabine alone or in combination with Campath cannot be excluded. Despite there being many documented side effects of Campath there are currently no reports in the literature of acute renal failure and DIC. The transplant had to be aborted and 9 months on the patient is still requiring dialysis twice a week.