SHM Converge Scientific Abstract ePoster Gallery-Hidden in Plain Sight

Pdf Summary

This case describes a 74-year-old woman with urothelial cancer, atrial fibrillation on warfarin, hypertension, diabetes, and prior stroke who was hospitalized for suspected infected hydronephrosis. She underwent ureteral stent placement, received broad-spectrum antibiotics, and later was restarted on a heparin drip after anticoagulation had been temporarily held. During recovery, she developed ongoing crampy abdominal pain, poor appetite, constipation, intermittent tachycardia, and occasional hypotension. Initial abdominal evaluation was unrevealing, including a normal abdominal X-ray.<br /><br />By day 6, her pain persisted, her hemoglobin dropped significantly, and she developed abdominal tenderness with peritoneal signs and intermittent hypotension. Repeat CT imaging revealed a large rectus sheath hematoma and a large extraperitoneal hematoma, consistent with spontaneous bleeding related to anticoagulation.<br /><br />The discussion emphasizes that spontaneous rectus sheath and retroperitoneal hematomas are important complications of anticoagulation, particularly intravenous heparin. Risk factors include older age, female sex, diabetes, hypertension, malignancy, anemia, prior stroke, chronic kidney disease, and other bleeding risks. Typical presentation includes abdominal pain, abdominal swelling or mass, hypotension, tachycardia, and falling hemoglobin.<br /><br />Management is usually conservative and includes stopping or reversing anticoagulation, transfusion support, and close hemodynamic monitoring. In selected cases, interventional radiology or surgery may be needed for embolization or further control of bleeding.<br /><br />The key lesson is that persistent postoperative abdominal pain in patients receiving anticoagulation should prompt a high index of suspicion for occult bleeding, even when early imaging is normal. In this patient, holding heparin, transfusing blood, and monitoring closely led to improvement, and anticoagulation was later restarted without further bleeding.

Asset Subtitle

Radha Devi Radhakrishna Pillai

Meta Tag

Author List Nathan Martin, Radha Devi Radhakrishna Pillai

Category Clinical Vignettes

Concept Heparin

Concept Rectus Sheath Hematoma

Concept Extraperitoneal Hematoma

Concept Abdominal Pain

Concept Hemoglobin

Distinguished Non-Finalist

Presenter Organization Washington University School of Medicine

Presenting Author Radha Devi Radhakrishna Pillai

Track Adult

Keywords

urothelial cancer

atrial fibrillation

warfarin

heparin anticoagulation

infected hydronephrosis

ureteral stent

rectus sheath hematoma

retroperitoneal hematoma

abdominal pain

occult bleeding

Heparin

Rectus Sheath Hematoma

Extraperitoneal Hematoma

Abdominal Pain

Hemoglobin