Case Report: Fatal mesenteric venous thrombosis and progressive bowel ischemia following right hemihepatectomy

Mesenteric venous thrombosis (MVT) is an uncommon but potentially fatal complication following major hepatic resection. We report the case of a 62-year-old cirrhotic male with Hepatitis B who underwent an open right hemihepatectomy with Roux-en-Y reconstruction for a suspected Bismuth-Corlette Type 3A Klatskin tumour. On postoperative day (POD) 4, he developed refractory metabolic acidosis with profound hyperlactatemia, prompting urgent CT imaging and exploratory laparotomy which revealed extensive patchy small bowel ischaemia consistent with MVT. Serial laparotomies demonstrated relentless progression to total intestinal infarction despite maximal surgical and intensive care intervention and the patient succumbed to septic shock and multi-organ failure on POD 14. This case illustrates how the convergence of Virchow's triad in the post-hepatectomy cirrhotic patient, namely portal stasis exacerbated by inadequate fluid resuscitation, cirrhosis-mediated hypercoagulability and surgical endothelial injury can precipitate a rapidly fatal thrombotic cascade. It further highlights the dual clinical dilemma of diagnostic elusiveness as early imaging may be falsely negative and therapeutic paralysis where the perceived haemorrhagic risk of anticoagulation in a coagulopathic patient may delay the only intervention capable of halting thrombus propagation. This case underscores the imperative for heightened clinical vigilance, proactive hydration and a low threshold for repeat vascular imaging in cirrhotic patients undergoing major hepatectomy. Early anticoagulation tailored to the individual patient's risk profile should be carefully considered upon clinical suspicion of MVT, even in the setting of apparent coagulopathy.