Spontaneous Abdominal Wall Hematoma Associated with the Use of Direct-Acting Oral Anticoagulants a Case Report

Introduction: Spontaneous rectus sheath hematoma (SRSH) is a rare and potentially fatal event; the literature describes anticoagulation as the main risk factor, especially with the use of warfarin. Few cases have been reported with the use of direct oral anticoagulants (DOAC) and most of them report another associated precipitating factor. We present a case of SRSH associated with the use of DOACs in which no other precipitating factor other than anticoagulation was identified.

Case presentation: 74-year-old woman who consulted at an IV level hospital in Bogotá due to abdominal pain and a palpable mass of sudden onset not associated with trauma. She had a history of recurrent venous thromboembolic disease for which she had been anticoagulated with rivaroxaban. Physical examination revealed a painful mass on the left flank, without peritoneal irritation. Angiotomography of abdominal vessels was performed, which showed a hematoma of the left rectus abdominis muscle with active bleeding from the inferior epigastric artery. No other related factors other than anticoagulation were found as a possible etiology. Selective arterial embolization was performed with adequate bleeding control, which allowed early resumption of anticoagulation.

Discussion: SRSH is a potentially fatal entity, anticoagulation is reported as the main associated factor, although it is an infrequent event with DOACs. Most of them also describe triggering factors such as coughing, straining, and vomiting and will require expectant management, however, early endovascular management should be considered for better outcomes.

Key words: hematoma, abdominal wall, anticoagulants, rivaroxaban, case report