A 29-year-old male was admitted with a 3-day history of increasing epigastric and back pain. With a raised serum amylase within the diagnostic limits for acute pancreatitis and with deranged liver function tests, the patient was started on the standard treatment for acute pancreatitis. This included intravenous fluids, oxygen, urine output monitoring with strict fluid balance charting, a proton-pump inhibitor, venous thromboembolism prophylaxis and antibiotics (in accordance with our local policy).An abdominal computer tomography (CT) scan performed two days after admission showed widespread necrotising pancreatitis. The patient deteriorated subsequently, becoming increasingly hypoxic and requiring intubation and ventilation. He was transferred to our unit for further care.The CT scan also revealed the presence of multiple thrombi throughout the length of the aorta. A CT aortogram was therefore performed after the patient was stabilised. This showed extensive arterial thrombus throughout the arch vessels and thoracic and abdominal aorta (Fig 1). The CT demonstrated thrombus present at the origin of the right innominate and left common carotid artery, and two separate large areas of thrombus present in the proximal and mid descending thoracic aorta. Further thrombus was present at the diaphragmatic hiatus, with yet more thrombus in the juxtarenal abdominal aorta, extending into the origin of the left renal artery. The coeliac trunk, splenic artery, common hepatic artery and superior mesenteric artery were unaffected. A thrombophilia screen was performed and was normal.The patient had a complicated past medical history, suffering from chronic pain syndrome since his early childhood, with widespread joint and muscle involvement. As such, he had been extensively investigated by rheumatologists, orthopaedic surgeons and psychiatrists. He was a heavy smoker and had been housebound for the previous two years.A CT scan had been performed one year prior to this episode as part of haematological investigations into the cause of a lymphocytosis. This did not show any evidence of aortic thrombus at that time (Fig 2). It would therefore seem likely that the cause of the widespread aortic thrombus formation was acute severe pancreatitis. The alternative is that the acute pancreatitis was secondary to the aortic thrombosis and visceral ischaemia. However, this is improbable as the coeliac trunk, superior mesenteric artery and their main branches were patent on the CT scan.The patient was anticoagulated with an intravenous heparin infusion on the basis that the risk from propagation of the aortic thrombus was greater than that of bleeding from his necrotic pancreas. The patient was successfully managed non-operatively on the intensive care unit for a total of eight days before being moved to the ward. Intravenous heparin infusion was then converted to subcutaneous low-molecular weight heparin at treatment dose. He continued to improve and was transferred back to the referring hospital for further management, including a cholecy...

The use of extended duration thromboprophylaxis following hip and knee arthroplasty is becoming widespread. The aim of our study was to determine patient compliance with extended duration thromboprophylaxis using low molecular weight (LMWH) injections following hip and knee arthroplasty. 42 consecutive patients undergoing hip and knee arthroplasty were prospectively contacted during their fifth post operative week. A fully anonymised questionnaire was completed by each patient. All patients responded. One was excluded having been prescribed warfarin for pre existing atrial fibrillation. Twenty nine (71%) patients were discharged with the intention of self administering LMWH injections. Eight (20%) and four (9%) patients were discharged with the intention of administration by a relative or district nurse respectively. No patient required the person administering the injections to be changed after discharge from hospital. 90% (n=37) of patients reported not missing any doses. 10% (n=2) of patients missed one dose and 10% (n=2) missed two doses. Patient compliance with extended duration thromboprophylaxis using LMWH injections is extremely high. Oral thromboprophylaxis may be useful in the minority of patients requiring daily visits by a nurse to administer injections.

No abstract

No abstract

No abstract