Massive retroperitoneal hematoma as a complication of anticoagulation therapy in a patient treated in a pulmonary intensive care unit

Mihailo Stjepanović; Ivana Buha; Snežana Raljević; Uroš Babić; Milan Savić; Jovana Mašković; Marina Roksandić; Dragana Marić

doi:10.2298/4531

Mihailo Stjepanović Clinic of Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia
Ivana Buha Clinic of Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia
Snežana Raljević Clinic of Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
Uroš Babić Clinic of Urology, Clinical Center of Serbia, Belgrade, Serbia
Milan Savić Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia
Jovana Mašković Clinic of Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia
Marina Roksandić Clinic of Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia
Dragana Marić Clinic of Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia

DOI: https://doi.org/10.2298/4531

Keywords: anticoagulants, drug toxicity, hemorrhage, hematoma, retroperitoneal space, treatment outcome,

Abstract

Introduction. Retroperitoneal hematoma may occur as a result of trauma, but also from rupture of arterial aneurysms (aortic or iliac), surgical complications, tumors or anticoagulation therapy. Case report. We presented a patient on permanent anticoagulation therapy. On the day of admission to our institution, the patient had the value of his INR 5.57 which required immediate suspension of the therapy. The main symptom in this patient was pain in the right inguinal canal with propagation along the right leg, which was indicated in clinical picture of spontaneous retroperitoneal haematoma. After three days the fall of hemoglobin occurred, so the additonal diagnostics was done. A computed tomography of the abdomen was performed showing well limited, large retroperitoneal hematoma (213 ´ 79 ´ 91 mm). Transfusion of concentrated red blood cells was performed twice with satisfactory correction of hemoglobin level, and four units of fresh frozen plasma. The patient was hemodynamically stabilized and discharged after a two-month long intensive care unit treatment, with the advice to use low-molecular weight heparin 2 ´ 0.4 mg subcutaneusly, due to persistent arrhythmia. Conclusion. In patients on anticoagulation therapy regular monitoring of the anticoagulant status is extremely important, because of the possibility of fatal complications development, such as retroperitoneal hematoma.

Author Biographies

Mihailo Stjepanović, Clinic of Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia

Ivana Buha, Clinic of Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia

Snežana Raljević, Clinic of Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia

Milan Savić, Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia

Jovana Mašković, Clinic of Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia

Marina Roksandić, Clinic of Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia

Dragana Marić, Clinic of Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia

References

Panetta T, Sclafani SJ, Goldstein AS, Phillips TF, Shaftan GW. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma 1985; 25(11): 1021−9.

Danaci M, Kesici GE, Kesici H, Polat C, Belet U. Coumadin-induced renal and retroperitoneal hemorrhage. Ren Fail 2006; 28(2): 129−32.

Pallea EX, Domingo P, Fontcubertta J, Felez J. Spontaneus terto-peritoneal haemorrhage during oral anticoagulant therapy. Arch Inrern Med 1985; 145(8): 1531−4.

Hirsh J, Dalen JE, Anderson DR, Poller L, Bussey H, Ansell J, et al. Oral anticoagulants: mechanism of action, clinical effec-tiveness, and optimal therapeutic range. Chest 2001; 119: 8S−21S.

The European Atrial Fibrillation Tril Study Group. Optimal oral anticoagulant therapy in patients with nonrheumatic atrial fi-brillation and recent cerebral ischemia. N Engl J Med 1995; 333: 5−10.

Hylek EM, Chang YC, Skates SJ, Hughes RA, Singer DE. Pros-pective study of outcomes of ambulatory patients with exces-sive Warfarin anticoagulation. Arch Inter Med 2000; 160(11): 1612−7.

Balci NC, Sirvanci M, Tüfek I, Onat L, Duran C. Spontaneous re-troperitoneal hemorrhage secondary to subcapsular renal he-matoma: MRI findings. Magn Reson Imaging 2001;19(8):1145-8.

Kirazli Y, Akkoc Y, Kanyilmaz S. Spinal epidural hematoma as-sociated with oral anticoagulation therapy. Am J Phys Med Rehabil 2004; 83(3): 220−3.

Crowther MA, Warkentin TE. Bleeding risk and the manage-ment of bleeding complications in patients undergoing anti-coagulant therapy: focus on new anticoagulant agents. Blood 2008; 111(10): 4871−9.

Sasson Z, Mangat I, Peckham KA. Spontaneous iliopsoas hema-toma in patients with unstable coronary syndromes receiving intravenous heparin in therapeutic doses. Can J Cardiol 1996; 12(5): 490−4.

Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30(2): 239−45.

Pless T, Loertzer H, Brandt S, Radke J, Fornara P, Soukup J. Atraumatic retroperitoneal hemorrhage: interdisciplinary and differential diagnostic considerations based on a case report. Anaesthesial Reanim 2003; 28(2): 50−3. (German)

Quartey B, Nelson J. Massive spontaneous retroperitoneal he-morrhage induced by enoxaparinand subsequent abdominal compartment syndrome requiring surgical decompression: a case report and literature review. IJCRI 2011; 2(10): 14−8.

Dentali F, Crowther M. Management of excessive anticoagulant effect due to vitamin K antagonists. Hematology Am Soc Hematol Educ Program 2008; 2008: 266−70.

Baglin T. Management of warfarin (coumarin) overdose. Blood Rev 1998; 12(2): 91−8.

Lubetsky A, Yonath H, Olchovsky D, Loebstein R, Halkin H, Ezra D. Comparison of oral vs intravenous phytonadione (vitamin K1) in patients with excessive anticoagulation: a prospective randomized controlled study. Arch Intern Med 2003; 163(20): 2469−73.

Ivascu FA, Janczyk RJ, Bair HA, Bendick PJ, Howells GA. Sponta-neous retroperitoneal hemorrhage. Am J Surg 2005; 189(3): 345−7.

Daliakopoulos SI, Bairaktaris A, Papadimitriou D, Pappas P. Gigantic retroperitoneal hematoma as a complication of anticoagulation therapy with heparin in therapeutic doses: a case report. J Med Case Rep 2008; 2(1): 162.