(P88) Abdominal Wall Hematoma in a High-risk Patient: Navigating the Complexities of Anticoagulation

Chief Complaint : Right lower quadrant abdominal pain and distension

History of Present Illness : 63 year old male with hypertension, diabetes, chronic kidney disease, atrial fibrillation, severe mitral regurgitation status post bioprosthetic mitral valve replacement on Coumadin, and recent transient ischemic attack presented with right lower quadrant abdominal pain and distention. Patient stated that this is his third visit to the emergency department for sharp, stabbing abdominal pain and swelling that has progressively worsened and radiated to his scrotum in the past twenty-four hours. He noted that superficial abdominal bruising began one week ago after his last Lovenox injection following a recent TIA in the setting of subtherapeutic INR on Coumadin. Prior abdominal surgeries include one exploratory laparotomy for a left abdominal stab wound over forty years ago.

Pertinent Physical Exam: Physical exam revealed a non-toxic patient in mild acute distress from pain. There was distension and severe tenderness localized to the right lower quadrant of the abdomen without guarding or rebound. Guaiac test was negative, however, mild scrotal swelling was present without overlying skin changes or significant tenderness. Cardiovascular and pulmonary examination were unremarkable. Patient was alert and oriented to person, place, time, and event.

Pertinent Laboratory Data: Initial CBC revealed a hemoglobin of 10.2 consistent with the patient’s baseline then dropped to 7.7 within twenty-four hours. CMP was unremarkable with kidney function consistent with known chronic kidney disease. INR of 2.6 was increased from 1.4 prior to receiving Lovenox. CT abdomen and pelvis with IV contrast showed a low-density collection in the right lower abdominal wall, most consistent with a hematoma, measuring 13.5 cm by 8.5 cm by 18.5 cm with suspicion for active extravasation of contrast. BMI was stable at 34.9.

Case Discussion: In the emergency department, the patient became hypotensive with systolic BP 70-90’s without significant sustained improvement after IV fluids. Repeat hemoglobin of 7.7 prompted transfusion of 2 units of packed RBCs, 2 units of FFP, and vitamin K followed by embolization by interventional radiology on day 1 of hospital admission. Per cardiology recommendations, the patient continued to receive blood transfusions to maintain hemoglobin greater than 8. On day 6, the patient’s clinical status worsened with a hemoglobin of 6.2 and a repeat CT scan that revealed an expanding hematoma. The patient received a final transfusion and underwent a second embolization by interventional radiology on day 7. Coumadin was held throughout the duration of admission with repeat daily INR consistent at 1.3. The patient remained hemodynamically stable with hemoglobin 8.6 and was discharged on day 11 with instructions to hold coumadin at home and cardiology follow-up.
In this case, the addition of a second anticoagulation agent should be done with caution and entail a detailed evaluation of risk and benefits. Older age, use of anticoagulation agents, and obesity predispose to the development of dangerous abdominal wall hematomas with possibly fatal consequences due to increased bleeding risk and different vascular structure and matrix composition of subcutaneous tissue [1]. Hemodynamic instability secondary to an abdominal wall hematoma is especially concerning for patients with multiple comorbidities who are poor candidates for surgical intervention. Relevant literature shows that mortality rates can range from four to twenty percent and conservative management is preferred for those with multiple chronic conditions given no increase in hematoma size and hemodynamic stability [2]. Careful consideration of anticoagulation regimens in patients with abdominal wall hematoma involving known risk factors, co-existing medical conditions, and early intervention can prevent sequelae, such as hemodynamic instability and fatality.

References and Acknowledgements (Optional): [1] Goldstein, J. M., & Sebire, D. (2013). Abdominal wall haematoma in the obese: a dangerous phenomenon. Journal of surgical case reports, 2013(7), rjt060. https://doi.org/10.1093/jscr/rjt060

[2] Çolakoğlu MK, Özdemir A, Kalcan S, Demir A, Demiral G, Pergel A. Spontaneous abdomen and abdominal wall hematomas
due to anticoagulant/antiplatelet use: Surgeons’ perspective in a single center. Ulus Travma Acil Cerrahi Derg 2020;26:50-54.