I have just operated on an interesting 27 yo obese male with Factor 5-linden hypercoagulopathy. I will present the case although my questions relate more to other problems. He presented in Dec with bilateral lower extremity DVT. In the course of his workup, which was extensive, he was noted to have large pelvic and abdominal venous collaterals with no evident inferior venacava. He was assymptomatic prior to Dec. He was seen by several hematologists in the Northeast and begun on high dose Coumadin with resolution of his swelliing, etc. In late March he presented with chest pain, V/Q scan was negative and he had an equivical sestamibi stress test. A cardiac cath was performed with abstinence from Coumadin for 7 days. The cath was negative but he presented to the ER later that day with chest pain. He was begun on Heparin and I was asked to see him. A repeat V/Q was negative, but on exam he had epigastric tenderness but no RUQ tenderness. A GB u/s showed stones and fluid around the GB. I operated on him (open) and performed an uneventful cholecystectomy for an acutely inflamed cholecystitis.
His INR was 3.6. I was a little worried about surgery with this much anticoagulation, but my hematologist told me the boy would still clot. He did. Bleeding was not a problem.
Throughout his course he has been told he has an absent inferior venacava. Since I was skeptical he would get 27 years before a problem, I looked while in the RUQ and found at least a retroduodenal cava that felt patent. Since CT and MRI were unsuccessful in delineating his problem, could anyone suggest further tests and also an appropriate referral in the Northeast US. So far he has only seen the high powered hematologists and his other problems have been ignored. Since this all began he has had several syncopal episodes with exertion which I suspect are on the basis of venous return.