Reversal of GI Bleeding with Idarucizumab in a Patient on Dabigatran and Incidental Finding of a Retroperitoneal Hematoma

Abstract

Introduction: The increase in use of anticoagulation has led to the development of many new drugs that target improved compliance. Because these drugs increase the risk of bleeding, the availability of reversal agents has become an important aspect when considering their prescription. We present a case of a 78 year old male on Dabigatran who presented with gastrointestinal (GI) bleeding from a marginal ulcer and was successfully treated with Idarucizumab. Case: Our patient is a 78 year old male with a history of atrial fibrillation (on Dabigatran), recent panreatectomy with Roux-en-Y reconstruction for intraductal papillary mucinous neoplasm who presented to the hospital with an episode of bloody bowel movement, dizziness and weakness. He had a pulse of 107 bmp and blood pressure of 91/44 mmHg. His physical exam was pertinent for lethargy and blood per rectum. Pertinent laboratory findings included creatinine of 1.2 mg/DL, hemoglobin of 11.1 g/dL and PTT of 86.6. Upon arrival to the emergency department, he was resuscitated with 1 L normal Saline and his BP improved to 118/55 mmHg. Since he was having a hemodynamically significant GI bleed, he was given Idarucizumab to reverse the anticoagulant effect. Subsequent lab findings revealed a PTT of 48 and hemoglobin of of 8.3 g/dL. Patient had an EGD which revealed patent enteroenterostomy characterized by congestion, erythema, friable mucosa, inflammation and ulceration, and evidence of extrinsic compression on the posterior stomach wall. CT scan of the abdomen showed a 19.7 cm x 9.1 cm x 8.0 cm heterogeneous collection of fluid in the retroperitoneal area. He subsequently went for a laparotomy and had evacuation and suturing of the bleeding splenic artery. Discussion: Dabigatran remains one of the safest new oral anticoagulant agents as it has a reversal agent recently FDA approved for life threatening bleeds. In our patient, the GI bleed was a direct consequence of his recent pancreatectomy with Roux-en-Y reconstruction as evident from the marginal ulceration and inflammation seen on EGD. His GI bleed subsequently resolved with eventual normalization of PTT signifying reversal of the affect of Dabigatran. What makes this case more interesting is the incidental discovery of a large retroperitoneal hematoma based on the extrinsic compression of the stomach found on EGD. This serves as a great reminder to always consider a retroperitoneal bleed in an anticoagulated patient with a recent GI surgery.