1. NEJM: CLINICAL PROBLEM-SOLVING
Kurdistan GEH Board journal club:

2. History:
 A 55-year-old man with a history of heart failure presented to the
emergency department with pain and swelling in his right foot and
leg.
 Three days beforepresentation, he noted a sudden onset of
swelling in the right foot and calf, without any prior trauma.
 The swelling worsened progressively, extending to the upper
leg&was accompanied by pain in the foot and calf.
 He doubled his usual dose of torsemide, with no effect.
 On the day of presentation, he noted new dusky discoloration of
the toes on his right foot.

3. History:
 The patient’s medical history was notable for obesity, paroxysmal atrial
fibrillation, hypertension& heart failure with a preserved ejection fraction.
 Medications included warfarin, sotalol, torsemide, and lisinopril.
 There was no personal or family history of arterial or venous thrombosis.
 The patient had a 30-pack-year smoking history but had quit smoking 5
years earlier. He drank about four beers every weekend.
 He reported an intentional weight loss of 22.7 kg (50 lb) over the preceding
6 months, which he attributed to a combination of diet and exercise.

4. On physical examination
 The patient’s temperature was 36.1°„C (97°„F), with a heart rate of 80 beats per
minute and a blood pressure of 96/50 mm Hg; the oxygen saturation was 95%
while he was breathing ambient air.
 The oropharyngeal examination was notable for poor dentition.
 The lungs were clear on auscultation bilaterally.
 The heart sounds were regular, with a normal S1, a physiologically split S2, and no
murmurs, rubs, or gallops.
 The jugular venous pressure was 8 cm of water.
 The abdomen was obese, soft, and nondistended, with normal bowel sounds and no
hepatosplenomegaly or masses.
 The legs were markedly asymmetric, with 4+ pitting edema of the upper right
thigh& 2+ pitting edema of the left calf. The right leg&foot were dusky and cold, &
distal pulses were detectable only on Doppler ultrasonography.

5. On physical examination
 On the right ankle and sole of the right foot, there were discrete hemorrhagic
bullae on a purpuric base with central, dusky discoloration
 The bullae were confluent over the dorsomedial aspect of the foot and toes.
 The entire right lower extremity was edematous but without eczematous change
or scaling.
 There was no purpura other than that associated with the bullous lesions.
 Pulses in the left leg were easily palpable, and there was no edema.
 Muscle tone and strength and sensation of pinprick and light touch were intact
and equal in both legs.

7. Lab tests:
 Na136 mmol per liter, K 4.6 mmol per liter, chloride 110 mmol per liter,
bicarbonate 23 mmol per liter
 BUN 62 ,cr 2.1 , glucose 114,1 month earlier, BUN 18 mg , cr 0.8
 ALT 31 U, AST 34 ,TSB 0.5 ,SAP 630 ,albumin 3.1.
 WBC 16,900,PCV 37.1%, platelet 283,000
 A peripheral-blood smear was negative for schistocytes.
 PT 42.3 seconds (INR, 4.3), PTT 89 seconds , fibrinogen 215 mg/ dl
 An U/S of the right leg showed noncompressibility of the deep veins, consistent
with thrombosis, extending from common femoral vein to the popliteal vein.

8. Actions:
 IV VK administered, after INR decreased to 1.5.
 IV UF heparin was initiated.
 Leg venography revealed complete occlusion of the right common
femoral vein, femoral vein &popliteal vein.
 After pulse-spray thrombectomy with a rheolytic catheter, a large
thrombus burden remained, prompting overnight catheter-directed
thrombolysis with tissue plasminogen activator (t-PA).
 The following day, a repeat venogram showed restored patency of
the venous system .

10. Actions:
 The t-PA catheter was removed, and systemic anticoagulation
therapy was resumed.
 Laboratory testing before the initiation of heparin therapy was
notable for a normal homocysteine level,normal results of an
antithrombin III functional assay & activated protein C resistance
testing.
 Results of testing for the prothrombin G20210A mutation were
negative, and antiphospholipid antibodies were not detected.

11. Imagings:
 The γ-GT 295 IU per liter (normal range, 0 to 40).
 Computed tomography of the abdomen and pelvis without the IV
contrast showed multiple hypodense liver lesions, up to 3 cm in
diameter&extensive periportal/ gastrohepatic retroperitoneal
lymphadenopathy& diffuse omental nodularity & caking &
irregular, masslike thickening of the greater curvature of the
stomach.

13. Endoscopy:
 OGD/EUS revealed a large, infiltrative, & centrally ulcerated mass on the greater
curvature of the stomach.
 Pathological exam revealed poorly differentiated, invasive adenocarcinoma.
 Progressive hypotension&renal failure developed, both of which were
unresponsive to fluid resuscitation.
 Treatment with IV dopamine / vasopressin was initiated.
 The vascular-surgery service was consulted for consideration of right-leg
amputation, but the patient declined the procedure, given his poor overall
prognosis.
 At his request, vasopressor therapy was withdrawn&comfort measures were
initiated; he died 10 days after admission.

15. Diagnosis:
 Gastric cancer-induced
Hypercoagulable state