Persistent Risk of Pulmonary Embolism in Acute Pancreatitis Despite Prophylactic Anticoagulation

Acute pancreatitis, a sudden inflammatory condition, can lead to a hypercoagulable state resulting in complications such as deep vein thrombosis (DVT) or pulmonary embolism (PE). This case report discusses a unique presentation of a massive PE in a patient with acute pancreatitis despite being on appropriate prophylactic anticoagulation. A 27-year-old man presented with acute abdominal pain, nausea, and vomiting. He was diagnosed with diabetic ketoacidosis (DKA) and acute pancreatitis and admitted to the ICU. He was treated with prophylactic enoxaparin. On day 16, he experienced acute respiratory decompensation, and CT angiography revealed bilateral PEs, including a right main pulmonary artery saddle embolus. The patient underwent emergent thrombectomy with the immediate resolution of symptoms. He was transitioned to therapeutic heparin and later discharged on apixaban. A two-month follow-up showed no recurrence of PE. This case underscores the critical need to consider PE in patients with inflammatory conditions, even when on prophylactic anticoagulation. The hypercoagulable state induced by pancreatitis can overcome standard anticoagulation measures, leading to severe complications. Current guidelines may not adequately address the anticoagulation needs in such inflammatory states. Therefore, weight-based dosing of anticoagulants should be considered for patients with significant inflammation. This report highlights the necessity for vigilance in monitoring for PE in similar clinical scenarios to improve patient outcomes and inform future guidelines.