Abstract
IntroductionSpontaneous 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 presentationWe 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.ConclusionDelay 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.
Highlights
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 diagnosis of atraumatic retroperitoneal hemorrhage remains challenging even when high-resolution magnetic resonance imaging (MRI) and Computed tomography (CT) imaging are used, because a large number of benign or malignant lesions can mimic this condition [18,19]. Despite these limitations, MRI and CT imaging are superior to ultrasound and should be the preferred primary investigation [20,21,22]. The rarity of this possible complication of the intravenous use of Heparin in patients with international normalized ratio (INR) < 4.5 means that it remains a challenge for surgeons
We strongly suggest that, according to our experience, daily measurement of INR and activated partial thromboplastin time in patient's receiving Heparin intravenously as an anticoagulation agent is of great importance
Summary
The rarity of this possible complication of the intravenous use of Heparin in patients with INR < 4.5 means that it remains a challenge for surgeons. We strongly suggest that, according to our experience, daily measurement of INR and activated partial thromboplastin time (aPTT) in patient's receiving Heparin intravenously as an anticoagulation agent is of great importance. In deep vein thrombosis or acute myocardial infarction, the usual protocol requires injection of Heparin monitored by the prothrombin time, aPTT or both followed by long-term therapy with oral anticoagulants. Some of the most important factors for the diagnosis are acute onset of pain, a dramatic change in the patient's clinical status and high clinical suspicion. The complex challenge for the surgeon is the choice of clinical pathway in the management of this rare entity and this choices should only be made after taking two key points into consideration: (i) the patient's general condition; (ii) in the presence of permanent femoral or sciatic neuropathy due to a compression syndrome, hemodynamically unstable patients should be managed with an emergency laparotomy
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
