Spontaneous rectus sheath haematoma due to cough on apixaban

Abstract

DesCripTionA 69-year-old woman on apixaban for 4 years due to her atrial fibrillation presented with severe left lower abdominal pain. She was discharged from the hospital 4 days prior after treatment for influenza and had finished a course of oseltamivir. She did not receive any heparin products and was continued on apixaban during that admission. A few hours before presentation, she reported coughing severely with sudden onset of excruciating abdominal pain. She denied trauma or injury to the abdomen. On exam, she was alert, normotensive and tachycardic, with significant left lower quadrant tenderness in the abdomen. Laboratory results were significant for decreased haemoglobin from 15.2 to 12.9 g/ dL. CT of the abdomen showed acute left inferior rectus abdominis muscle haematoma (7.5 cm), along with stable and unchanged left adnexal cystic lesion (figure 1). Apixaban was discontinued, and the patient was closely monitored in the hospital with supportive care. Her haemoglobin remained stable and her pain improved. Repeat CT showed stable rectus sheath haematoma. She was asked to withhold apixaban for 1 week and was discharged to follow-up with her primary care physician to restart it.About one in six emergency department visits for adverse drug events is due to bleeding in patients taking anticoagulant medications, and direct oral anticoagulants (DOAC) account for 10% of these events.1 Only four cases of DOAC-associated rectus sheath haematoma have been reported, two associated with apixaban and two with rivaroxaban.2 Rectus sheath haematoma is a rare but serious complication associated with significant morbidity and occasional mortality. It is the result of bleeding into the rectus sheath from damage to the superior or inferior epigastric arteries. Common risk factors and causes of rectus sheath haematoma include anticoagulation, blunt or penetrating trauma, pregnancy, female gender, older age, hypertension, medical conditions such as collagen vascular disorders, and increased abdominal pressure from straining or severe coughing.2 Ultrasound is the initial test of choice, but CT of the abdomen will help to identify the origin, location and extent of bleeding. Management of rectus sheath haematoma depends on several factors such as the severity and size of the haematoma, the haemodynamic status of the patient and the extent of anticoagulation. Treatment includes usual supportive measures, including interventional source control when indicated.2 No guidelines exist to direct the timing of anticoagulation resumption in patients with spontaneous rectus sheath haematomas. The requirement for anticoagulation should be weighed against the risk of rebleeding once the haematoma is stable. For severe DOAC-related bleeding, prothrombin complex concentrate and recombinant activated factor VII have been recommended.1 Current research focuses on antidotes to neutralise the anticoagulant activity of DOACs, including both direct thrombin inhibitors and direct factor Xa (FXa) inhibitors. Idarucizumab is licensed for the rapid...

Spontaneous rectus sheath hematoma associated with apixaban in an elderly gentleman with chronic obstructive airway disease

“…As the time of writing, only 6 case reports of DOAC-associated RSH, with three associated with apixaban and three associated with rivaroxaban. (5,(8)(9)(10)(11)(12) The majority of patients were female and all of them were older than 65 years of age. Drug interaction and reduced renal function may be contributing factors to the development of RSH in some of the cases (Table 1).…”

Fatal rectus sheath hematoma: a rare autopsy phenomenon

“…On rare occasions, it can also occur spontaneously (Kapan et al, 2008;Athanasios et al, 2014;McCarthy & Bellam, 2010;Patel et al, 2016). Among all of the factors mentioned above, direct blunt abdominal trauma and the use of anticoagulants are the most commonly reported risk factors (Alla et al, 2010;Elango et al, 2018;Donaldson et al, 2007;Cherry & Mueller, 2006).…”

A Review of the Incidence Diagnosis and Treatment of Spontaneous Hemorrhage in Patients Treated with Direct Oral Anticoagulants

“…Gunasekaran et al, reported a case of spontaneous rectus sheath hematoma in a 68-year-old female taking apixaban for a provoked VTE after a recent knee replacement surgery. She required two units of packed red blood cell transfusion and an IVC filter placement as anticoagulation was discontinued [39,40]. Aktas et al, reported a case of spontaneous rectus sheath hematoma in a 71-year-old female with atrial fibrillation taking apixaban [41].…”

“…Immediate discontinuation of the offending medication is essential for all patients, but the consequence of discontinuation of such agents due to thromboembolic events needs to be considered [78]. The half-lives of these DOACs are short; hence, there could be thrombotic events when withholding the agents even for a short period [40]. Therefore, in minimal bleeding, it may not be required to hold the anticoagulant at all.…”