Case Report

Surgical Management of Enoxaparin- and/or Warfarin-induced Massive Retroperitoneal Bleeding: Report of a Case and Review of the Literature

Authors: Koray Topgül, MD, Oğuz Uzun, MD, A Ziya Anadol, MD, Ali Gök,,MD

Abstract

A 70-year-old man on enoxaparin and warfarin sodium therapy due to pulmonary embolism was admitted for evaluation of a sudden, sharp pain in the left inguinal region. Physical examination revealed a 5 × 10 cm tender mass. Abdominal ultrasound showed a 9 × 9 × 10 cm left retroperitoneal hematoma. INR was 2.1, and anticoagulation therapy was discontinued. A regimen of supportive therapy (vitamin K, fresh frozen plasma and blood transfusion) was started, but the hemorrhage continued to enlarge, up to 9 × 10 × 20 cm, and the patient experienced a significant deterioration in his overall status. He underwent an urgent laparotomy and the hematoma was evacuated. A retroperitoneal abscess developed during the postoperative period which was drained percutaneously. He was discharged on postoperative day 33 with no further complaints. This case demonstrates the importance of surgical therapy in the treatment of spontaneous retroperitoneal hemorrhage caused by anticoagulant therapy.


Key Points


* Enoxaparin treatment is widely used for different types of patients in both surgical and nonsurgical practice.


* Spontaneous bleeding is one of the complications of this treatment. Although most cases are treated by conservative means, some need surgical intervention.


* We discuss potential side effects of enoxaparin as well as the need for surgical intervention with emphasis on appropriate timing for surgical intervention.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1.Bratt G, Törnebohm E, Locker D et al. A human pharmacological study comparing conventional heparin and a low molecular weight heparin fragment. Thromb Haemost 1985;53:208–211.
 
2.Chiu WS. The syndrome of retroperitoneal hemorrhage and lumbar plexus neuropathy during anticoagulant therapy. South Med J 1976;69:595–599.
 
3.Houde JP, Steinberg G. Intrahepatic hemorrhage after use of low-molecular-weight heparin for total hip arthroplasty. J Arthroplasty 1999;14:372–374.
 
4.Noble S, Spencer CM. Enoxaparin: A review of its clinical potential in the management of coronary artery disease. Drugs 1998;56:259–272.
 
5.Lensing AWA, Prints MH, Davidson BL et al. Treatment of deep venous thrombosis with low-molecular-weight heparins. A meta-analysis. Arch Intern Med 1995;155:601–607.
 
6.Findik S, Erkan ML, Selcuk MB, et al. Low-molecular-weight heparin versus unfractionated heparin in the treatment of patients with acute pulmonary thromboembolism. Respiration 2002;69(5):440–444.
 
7.Hyers TM, Agnelli G, Hull RD et al. Antithrombotic therapy for venous thromboembolic disease. Chest119(Suppl 1):176–193, 2001.
 
8.Antonelli D, Fares L, Anene CH. Enoxaparin associated with huge abdominal wall hematomas: A report of two cases. Am Surg 200;66:797–800.
 
9.Kumar PD. Thigh hematoma after femoral venipuncture in a patient treated with low molecular-weight heparin. Arch Intern Med 2001;161:1113–1114.
 
10.Wysowski DK, Talarico L, Bacsanyi J et al. Spinal and epidural hematoma and low-molecular-weight heparin. New Engl J Med 1998;338:1174–1175.
 
11.Klein SM, D’Ercole F, Greengras RA et al. Enoxaparin-associated with psoas hematoma and lumbar plexopathy after lumbar plexus block. Anesthesiology 1997;87:1576–1579.
 
12.Montoya JP, Pokala N, Melde SL. Retroperitoneal hematoma and enoxaparin. Ann Intern Med1999;131:796–797.
 
13.Dabney A, Bastani B. Enoxaparin-associated severe retroperitoneal bleeding and abdominal compartment syndrome: A report of two cases. Intensive Care Med 2001;27:1954–1957.
 
14.Chan-Tack KM. Fatal spontaneous retroperitoneal hematoma secondary to enoxaparin. South Med J2003;96:58–60.
 
15.Vaya A, Mira Y, Aznar J et al. Enoxaparin-related fatal spontaneous retroperitoneal hematoma in the elderly. Thromb Res 2003;110:69–71.
 
16.Melde SL. Enoxaparin induced retroperitoneal hematoma. Ann Pharmacother 2003;37:822–824.
 
17.Mrug M, Mishra PV, Lusane HC et al. Hemothorax and retroperitoneal hematoma after anticoagulation with enoxaparin. South Med J 2002;95:936–938.
 
18.Weitz J. Low-molecular-weight heparins. N Engl J Med 1997;337:688–698.
 
19.Camphell NR, Hull RD, Brant R et al. Aging and heparin-related bleeding. Arch Intern Med1996;156:857–860.