Why this case matters

Venous thromboembolism (VTE) prophylaxis is generally guided by established patient and procedural risk factors. This report describes a rare case of extensive bilateral lower-extremity deep vein thrombosis (DVT) following an otherwise uncomplicated open appendectomy in a young patient without inherited thrombophilia or major traditional risk factors. The case emphasizes that postoperative inflammation and modest lifestyle risks, such as smoking, may occasionally be sufficient to precipitate clinically significant thrombosis even after low-risk surgery.

Case summary

A 26-year-old Iraqi man presented 5 days after uncomplicated appendectomy with painful bilateral leg swelling, worse on the right. Doppler ultrasonography demonstrated extensive acute bilateral DVT involving the iliac, common femoral, superficial femoral, and popliteal venous systems. Laboratory testing revealed elevated CRP, ESR, and D-dimer, while thrombophilia screening was negative. He was successfully treated with low-molecular-weight heparin followed by 6 months of rivaroxaban, compression therapy, and close follow-up, without thrombus progression or recurrence.

Key learning points

• Extensive DVT may rarely occur after seemingly low-risk operations.
• Acute postoperative inflammation may contribute substantially to hypercoagulability.
• Smoking may amplify perioperative thrombotic risk, even in otherwise healthy individuals.
• Persistent postoperative leg pain or swelling should prompt early venous duplex imaging regardless of perceived surgical risk.
• Better individualized VTE risk stratification may be warranted for selected patients undergoing minor surgery.

Clinical take-home message

Although routine pharmacologic prophylaxis is not recommended for all low-risk appendectomy patients, clinicians should maintain a high index of suspicion for postoperative DVT when new lower-extremity symptoms develop. Early diagnosis and anticoagulation remain essential to prevent pulmonary embolism and long-term post-thrombotic complications.

Multiple Choice Question

A previously healthy 26-year-old man develops bilateral lower-extremity swelling 5 days after an uncomplicated open appendectomy. Doppler ultrasound confirms extensive bilateral DVT, and thrombophilia testing is negative. According to this case report, which factor was considered the most likely contributor to his thrombosis?

A. Inherited protein C deficiency
B. Malignancy-associated hypercoagulability
C. Postoperative inflammatory hypercoagulability with smoking as a contributing factor
D. Prolonged postoperative immobilization

Correct answer: C. Postoperative inflammatory hypercoagulability with smoking as a contributing factor

Explanation

The patient lacked inherited thrombophilia, malignancy, obesity, prolonged immobilization, or other classic VTE risk factors. The authors propose that the inflammatory response from acute appendicitis and surgery, reflected by markedly elevated CRP, ESR, and D-dimer levels, likely created a transient hypercoagulable state. His modest smoking history may have further promoted endothelial dysfunction and platelet activation, contributing synergistically to thrombosis. This case highlights that clinically important VTE can occasionally develop even after uncomplicated, low-risk surgery in otherwise healthy individuals.

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