Gigantic retroperitoneal hematoma as a complication of anticoagulation therapy with heparin in therapeutic doses: a case report

Abstract

Introduction: Spontaneous retroperitoneal hemorrhage is a distinct clinical entity that can present as a rare life-threatening event characterized by sudden onset of bleeding into the retroperitoneal space, occurring in association with bleeding disorders, intratumoral bleeding, or ruptures of any retroperitoneal organ or aneurysm. The spontaneous form is the most infrequent retroperitoneal hemorrhage, causing significant morbidity and representing a diagnostic challenge.

Case presentation: We report the case of a patient with coronary artery disease who presented with transient ischemic attack, in whom anticoagulant therapy with heparin precipitated a massive spontaneous atraumatic retroperitoneal hemorrhage (with international normalized ratio 2.4), which was treated conservatively.

Conclusion: Delay in diagnosis is potentially fatal and high clinical suspicion remains crucial. Finally, it is a matter of controversy whether retroperitoneal hematomas should be surgically evacuated or conservatively treated and the final decision should be made after taking into consideration patient's general condition and the possibility of permanent femoral or sciatic neuropathy due to compression syndrome.

Figure 1

MRI – transverse plan (L4) with IV contrast gadolinium-BOPTA, revealing a well-defined mass, a huge retroperitoneal hematoma.

Figure 2

MRI – axial plan showing a large, mixed density mass in the right side of the abdomen suggestive of a large retroperitoneal hematoma, with areas of hyperdensity (arrows) indicating ongoing hemorrhage.

Figure 3

MRI – coronar plan.