Collateral Damage

A CLINICAL PROBLEM-SOLVING article by Daniel Clayburgh from University of Chicago.
A 50-year-old white man presented to the emergency room with an 18-hour history of severe right-sided abdominal and flank pain.
One week earlier, he was hospitalized and diagnosed with widespread deep-vein thrombosis in the left leg. His only known risk factor was an airline flight from Rome to Chicago 1 month earlier. The results of an extensive hypercoagulability workup were normal.
Anticoagulation was initiated with enoxaparin with a transition to warfarin, and he was discharged home 4 days before this admission. On presentation, he was still taking both enoxaparin and warfarin. He awoke early in the morning with severe right-sided abdominal and flank pain.
In the last few hours before presentation his urine had changed to a dark tea color.
This patient's most recent hospitalization was for a classic presentation of a deep-vein thrombus; however, the recent airline flight may be a red herring, since immobility sitting on an airplane several weeks earlier seems unlikely to have contributed to the development of deep-vein thrombosis.
Although this patient's presentation suggested the possible need for surgical intervention, a thorough and methodical investigation coupled with the patience of the patient, who was medically stable, ultimately yielded a diagnosis that was managed with conservative treatment, avoiding unnecessary invasive intervention.

「重複下大静脈の１例」などを参照すると、１％程度の発生率で、多くはないが極端に稀ではない奇形であることを認識しておく必要がある。右胸心が１万人に１人、奇静脈葉が0.4%程度と言われているので、それらよりは多い頻度であるということを知っておいたほうがいいでしょう。