A 66-year-old woman was admitted for bilateral pulmonary thromboembolism under anticoagulant therapy with enoxaparin, starting 72 hours later with oral anticoagulation with acenocoumarol.
On the eighth day of admission, with an INR of 2.1, the patient develops, after a self-limiting emetic episode, a picture of general malaise, sweating, tendency to hypotension and abdominal pain abdominal CT scan performed 11 cm.
Anemization was important (decrease in hemoglobin of 4.2 g/dl in 72 hours), so in the presence of hemorrhagic shock due to a large abdominal wall hematoma, vigorous anticoagulation was initiated with urgent fluid replacement.
a persisting hemoperitoneum due to hemodynamic instability with initial conservative management and the appearance of acute abdomen semiology, it was decided to perform an urgent laparotomy showing "stallied" of the parietal peritoneum and of the right anterior rectus muscle
After support in the Intensive Care Unit and implantation of temporary inferior vena cava filter, the patient was discharged and anticoagulant therapy with acenocoumarol was restarted.
1.
Abdominal wall hematoma is an uncommon and difficult to diagnose entity that is usually related to systemic anticoagulation.
Anticoagulation is involved in its pathogenesis as a predisposing factor and vigorous contraction of the rectus abdominis muscles within sudden and energetic Valsalva movements (triggering factors, vomiting, constipation) as
Several previous studies have documented laceration of epigastric arteries as the cause of abdominal wall hematoma (1-6).
The diagnosis is based on the clinical context and the findings of abdominal imaging tests.
The usual clinical presentation consists of abdominal pain, and the physical examination may show an abdominal mass with or without signs of peritoneal irritation and/or a superficial hematoma.
Ultrasound usually documents the presence of a collection at the level of the abdominal wall and CAT is the technique of choice because it allows defining and specifying the extent of the process and involvement of organs.
Its management is usually conservative, even in the presence of clinical findings of acute abdomen (1.3), since the hematoma itself exerts a self-taponade effect, being sufficient symptomatic treatment and blood transfusion if necessary.
However, there are situations in which bleeding can be very severe and life-threatening, requiring a surgical approach to locate the bleeding point and drain the hematoma.
Successful treatment by endovascular embolization of bleeding vessels has also been described (1).
Hemodynamic instability, in spite of medical treatment instituted and/or the appearance of complications (chronic infection, superinfection, etc.) are the main indications for surgical treatment, as occurred in the present case.
Our experience confirms the importance of early diagnosis of abdominal wall hematoma and the need to carry out an individualized management of the same, since it is an entity that, although generally mild and self-limiting, requires conservative management of hemorrhagic viscera, etc.
1.
J. F. Varona, R. Diaz-Condiagnoses1, Ma. Valle, F. Muñoz2 and M. A. Bufalá Departments of Internal Medicine, 1Cirugía General and 2R.
Hospital El Escorial.
San Lorenzo del Escorial, Madrid
