Intestinal obstruction as a result of intra-abdominal hematoma: a complication of low molecular weight heparin in pediatric patients. / Obstrucción intestinal por hematoma intraabdominal: una complicación de la heparina de bajo peso molecular en el paciente pediátrico.

INTRODUCTION: Hematomas are a rare cause of intestinal obstruction. Subcutaneous heparin can bring about direct punctures on small bowel loops, potentially leading to traumatic hematoma and intestinal obstruction. CASE REPORTS: We present three cases of pediatric patients with clinical signs of intestinal obstruction treated with subcutaneous heparin. Two cases had increased acute-phase reactants and radiological signs of intestinal suffering, so surgical treatment was decided upon, with intramural hematoma emerging as an intraoperative finding. The third case was conservatively managed with anticoagulant discontinuation and gut rest, since the patient had an adequate general condition and no findings compatible with ischemia or necrosis were noted in the complementary tests. DISCUSSION: The administration of subcutaneous heparin may cause intestinal wall hematomas due to its anticoagulating effect and to the risk of inadvertent punctures on small bowel loops.

INTRODUCCION: Los hematomas son una causa poco frecuente de obstrucción intestinal. La heparina subcutánea tiene riesgo de producir la punción directa de un asa intestinal, provocando un hematoma traumático que genere una obstrucción intestinal. CASOS CLINICOS: Se describen tres casos de pacientes pediátricos con clínica de obstrucción intestinal en tratamiento con heparina subcutánea. Dos casos presentaron elevación de reactantes de fase aguda y signos radiológicos de sufrimiento intestinal por lo que se optó por tratamiento quirúrgico, con el hallazgo intraoperatorio de hematoma intramural. El tercer caso fue manejado de manera conservadora con supresión de la anticoagulación y reposo intestinal, dado el adecuado estado general y ausencia de hallazgos compatibles con isquemia o necrosis en las pruebas complementarias. COMENTARIOS: La administración de heparina subcutánea puede provocar la aparición de hematomas de pared intestinal, tanto por su efecto anticoagulante, como por el riesgo de punción inadvertida de un asa intestinal.

Warfarin Woes: A Rare Case of Hemoperitoneum with Intramural Small Bowel Hematoma.

BACKGROUND Small bowel hematoma is a rare yet clinically significant condition characterized by the accumulation of blood within the mucosa and submucosa layers of the small intestine wall. It can lead to complications such as bowel obstruction, ischemia, perforation, and even hemorrhagic shock. The etiology of intramural small bowel hematoma is diverse, encompassing factors such as anticoagulant therapy, coagulopathies, vascular disorders, trauma, and underlying systemic conditions. CASE REPORT We present the case of a 67-year-old man with a history of aortic valve replacement who presented with intense abdominal pain. Physical examination revealed generalized abdominal tenderness and black stools upon rectal examination. Laboratory tests indicated coagulopathy with a prolonged thrombin time. A computed tomography scan confirmed the presence of an intramural small bowel hematoma and hemoperitoneum. The patient's condition significantly improved within 48 h under conservative management, including nasogastric tube insertion, continuous monitoring of gastric aspirate, nil per os status, intravenous fluids, and analgesics. Warfarin was temporarily stopped, and fresh frozen plasma was administered for anticoagulation reversal. Heparin infusion was initiated once the INR became within the therapeutic level. CONCLUSIONS The occurrence of spontaneous intramural small bowel hematoma, although rare, demands rapid diagnosis and prompt, well-coordinated management. This case underscores the pivotal role of multidisciplinary collaboration in providing a comprehensive assessment and a tailored approach to treatment. While conservative measures, including careful monitoring and supportive care, have demonstrated favorable outcomes, the consideration of surgical intervention remains crucial, particularly in severe cases.

Intra-abdominal hematomas and identifiable risk factors in patients receiving subcutaneous enoxaparin.

BACKGROUND: Low molecular weight heparin has proven to be safe and effective but is not without potential risks such as spontaneous bleeding in the abdominal cavity. There is limited evidence evaluating the true incidence of this potential risk and the available literature is primarily via case reports. CASE SUMMARY: The purpose of this study was to identify the incidence and risk factors associated with enoxaparin use (prophylaxis or treatment) abdominal hematomas in a 350-bed community hospital during an 8-month time period. A total of 44 patients were identified as clinically significant bleeds receiving enoxaparin treatment or prophylactic therapy. Ultimately, 25 patients were excluded from the analysis due to an external cause of the abdominal hematoma or a temporal mismatch in enoxaparin administration and hematoma formation. After exclusion, there were a total of 19 patients that were assessed for the risk factors such as age, gender, renal function, and weight. After evaluation of risks, over half of the patients developing a clinically significant bleed were considered elderly (>65 years of age) and impaired renal function with a creatinine clearance of 60ml/min or less. CONCLUSION: Patients at risk for an enoxaparin associated hematoma include female patients with a CrCl <60ml/min and/or BMI >30 kg/m2 receiving enoxaparin treatment dosing.

Topical Use of Low-dose Tranexamic Acid Has no Effect on Drainage Volume after Medial Open Wedge High Tibial Osteotomy: A Case Control Study.

OBJECTIVE: Many studies reported that tranexamic acid (TXA) was effective in reducing surgical blood loss in the perioperative period of medial open wedge high tibial osteotomy (MOWHTO). However, few studies focused on the simple topical use of TXA in MOWHTO, and the modality and dosage of topical use of TXA varied. The purpose of this study was to observe the effect of topical use of low-dose TXA on drainage volume after MOWHTO, and to analyze the related influencing factors. METHODS: Data of patients who underwent MOWHTO combined with arthroscopic knee surgery in our department from January 2019 to September 2021 were retrospectively analyzed. A total of 105 patients (38 males and 67 females, aged 57.7 ± 7.5 years) were included in this study who received topical TXA or no TXA. The patients were divided into three groups: control group (39 cases), 0.5 g TXA group (40 cases), 1 g TXA group (26 cases). Postoperative drainage volume, wound healing, incidence of hematoma and deep venous thrombosis (DVT) were observed and analyzed in the three groups. The effects of gender, hypertension and diabetes on postoperative drainage volume were analyzed using a t-test. The correlation between age, body mass index (BMI), osteotomy gap and postoperative drainage volume were analyzed using the Pearson correlation coefficient. RESULTS: The average postoperative drainage volume of the control group was 259.54 ± 226.33 mL, that of the 0.5 g TXA group was 277.18 ± 177.68 mL, and that of the 1 g TXA group was 229.15 ± 219.93 mL. There was no statistically significant difference in postoperative drainage volume among the three groups (F = 0.423, p = 0.656). There was no local hematoma and wound infection in the three groups. The wound fat liquefaction was found in one patient of the control group. The incidence of DVT was 38.9% (7/18) and 57.1% (8/14) in the control group and 0.5 TXA group, respectively. There was no significant difference in the incidence of DVT between the above two groups (p = 0.476). The average postoperative drainage volume of male patients in the three groups was higher than that of female patients, and the differences were statistically significant (p < 0.05). There was no correlation between age, BMI, osteotomy gap and postoperative drainage volume in the three groups (p > 0.05). CONCLUSION: Topical use of low-dose TXA has no significant effect on drainage volume after MOWHTO. The drainage volume after MOWHTO in male patients was more than that in female patients. Topical administration of low-dose TXA does not increase postoperative complications, such as DVT and hematoma.

Warfarin induced spontaneous gastric intramural haematoma presenting with palpitations.

Spontaneous gastric intramural haematoma is an uncommon complication associated with anticoagulant therapy. A patient receiving chronic warfarin for paroxysmal atrial fibrillation was admitted due to atrial fibrillation with rapid ventricular response (RVR). An incidental intra-abdominal mass was detected on a CT scan. Following the initiation of the amiodarone infusion, the patient experienced bleeding attributed to warfarin-amiodarone-induced coagulopathy, with no identifiable bleeding source. Subsequent CT scans revealed an enlargement of the intra-abdominal mass, suggesting gastric intramural haematoma. After coagulopathy reversal, the haematoma is managed conservatively. Our case underscores the potential for incidental bleeding even when the international normalised ratio is within the normal range in patients on chronic warfarin therapy. When managing such patients with atrial fibrillation with RVR, physicians should maintain a high index of suspicion for bleeding, emphasising the importance of prompt coagulopathy reversal.

Nephrotic syndrome with rectus sheath hematoma: a case report.

BACKGROUND: Rectus sheath hematoma is a rare presentation often associated with abdominal trauma and anticoagulant therapy. Here, we present a patient with severe rectus sheath hematoma accompanied by nephrotic syndrome who achieved significant clinical improvement without the need for invasive treatment. CASE PRESENTATION: A 72-year-old Japanese woman was referred to our hospital for the treatment of nephrotic syndrome. She was receiving steroid and anticoagulant therapy. Then she had abdominal pain and she was diagnosed with spontaneous rectus sheath hematoma by abdominal computed tomography. She received transfusion and was managed conservatively with bed rest, which led to improvement in abdominal pain. CONCLUSION: Despite the absence of trauma history, rectus sheath hematoma should be considered in patients at risk of vascular failure, including those receiving anticoagulant or steroid therapy, those who are elderly, and those with nephrotic syndrome.

Prothrombin Complex Concentrate vs Conservative Management in ICH Associated With Direct Oral Anticoagulants.

Importance: Intracerebral hemorrhage (ICH) associated with direct oral anticoagulant (DOAC) use carries extremely high morbidity and mortality. The clinical effectiveness of hemostatic therapy is unclear. Objective: To compare the clinical and radiological outcomes of DOAC-associated ICH treated with prothrombin complex concentrate (PCC) vs conservative management. Design, Setting, and Participants: In this population-based, propensity score-weighted retrospective cohort study, patients who developed DOAC-associated ICH from January 1, 2016, to December 31, 2021, in Hong Kong were identified. The outcomes of patients who received 25 to 50 IU/kg PCC with those who received no hemostatic agents were compared. Data were analyzed from May 1, 2022, to June 30, 2023. Main Outcomes and Measures: The primary outcome was modified Rankin scale of 0 to 3 or returning to baseline functional status at 3 months. Secondary outcomes were mortality at 90 days, in-hospital mortality, and hematoma expansion. Weighted logistic regression was performed to evaluate the association of PCC with study outcomes. In unweighted logistic regression models, factors associated with good neurological outcome and hematoma expansion in DOAC-associated ICH were identified. Results: A total of 232 patients with DOAC-associated ICH, with a mean (SD) age of 77.2 (9.3) years and 101 (44%) female patients, were included. Among these, 116 (50%) received conservative treatment and 102 (44%) received PCC. Overall, 74 patients (31%) patients had good neurological recovery and 92 (39%) died within 90 days. Median (IQR) baseline hematoma volume was 21.7 mL (3.6-66.1 mL). Compared with conservative management, PCC was not associated with improved neurological recovery (adjusted odds ratio [aOR], 0.62; 95% CI, 0.33-1.16; P = .14), mortality at 90 days (aOR, 1.03; 95% CI, 0.70-1.53; P = .88), in-hospital mortality (aOR, 1.11; 95% CI, 0.69-1.79; P = .66), or reduced hematoma expansion (aOR, 0.94; 95% CI, 0.38-2.31; P = .90). Higher baseline hematoma volume, lower Glasgow coma scale, and intraventricular hemorrhage were associated with lower odds of good neurological outcome but not hematoma expansion. Conclusions and Relevance: In this cohort study, Chinese patients with DOAC-associated ICH had large baseline hematoma volumes and high rates of mortality and functional disability. PCC treatment was not associated with improved functional outcome, hematoma expansion, or mortality. Further studies on novel hemostatic agents as well as neurosurgical and adjunctive medical therapies are needed to identify the best management algorithm for DOAC-associated ICH.

A decade of experience in over 300 surgically treated spine patients with long-term oral anticoagulation: a propensity score matched cohort study.

PURPOSE: The aim of this study was to investigate the risks and outcomes of patients with long-term oral anticoagulation (OAC) undergoing spine surgery. METHODS: All patients on long-term OAC who underwent spine surgery between 01/2005 and 06/2015 were included. Data were prospectively collected within our in-house Spine Surgery registry and retrospectively supplemented with patient chart and administrative database information. A 1:1 propensity score-matched group of patients without OAC from the same time interval served as control. Primary outcomes were post-operative bleeding, wound complications and thromboembolic events up to 90 days post-surgery. Secondary outcomes included intraoperative blood loss, length of hospital stay, death and 3-month post-operative patient-rated outcomes. RESULTS: In comparison with the control group, patients with OAC (n = 332) had a 3.4-fold (95%CI 1.3-9.0) higher risk for post-operative bleeding, whereas the risks for wound complications and thromboembolic events were comparable between groups. The higher bleeding risk was driven by a higher rate of extraspinal haematomas (3.3% vs. 0.6%; p = 0.001), while there was no difference in epidural haematomas and haematoma evacuations. Risk factors for adverse events among patients with OAC were mechanical heart valves, posterior neck surgery, blood loss > 1000 mL, age, female sex, BMI > 30 kg/m2 and post-operative PTT levels. At 3-month follow-up, most patients reported favourable outcomes with no difference between groups. CONCLUSION: Although OAC patients have a higher risk for complications after spine surgery, the risk for major events is low and patients benefit similarly from surgery.

Spontaneous retroperitoneal and intracranial hemorrhage following streptokinase therapy in acute myocardial infarction: An autopsy case report.

Bleeding complications following thrombolytic treatment for acute myocardial infarction (AMI) are not infrequent, among which intracranial hemorrhage is commonly reported. In contrast, retroperitoneal hematoma following the administration of thrombolytics is rarely reported in the literature. We are reporting a case of a middle-aged man, who presented with left-sided chest pain and was diagnosed with acute coronary syndrome with anterior wall ST elevation AMI. The patient was administered with thrombolytic drugs, including streptokinase and heparin. Percutaneous coronary intervention in the form of Coronary angioplasty with stent insertion was done to the left anterior descending artery, given coronary artery disease. The blood investigations showed elevated activated partial thromboplastin time and prothrombin time. The patient developed vomiting, altered sensorium, and left-sided weakness, and a non-contrast computerized tomography brain was done, which showed acute hemorrhage involving the right frontal lobe with intraventricular extension, so the ventricular drain was placed. The patient developed cardiac arrest and died on the third day. On autopsy examination, the brain showed subarachnoid hemorrhage, intraparenchymal hemorrhage over the right frontal lobe, and clotted blood in all the ventricles. A retroperitoneal hematoma of around 1500 cc was seen over the left side of the peritoneal cavity. This case highlights that although intracranial hemorrhage is a known complication after administrating thrombolytic therapy, clinicians should also be aware of the possibility of retroperitoneal hemorrhage. This case emphasizes the value of an autopsy in determining the cause of death in such situations.

Prothrombin complex concentrate administration timing in warfarin-associated intracranial hemorrhage.

INTRODUCTION: Guidelines recommend "rapid" and "urgent" reversal of anticoagulation for warfarin-associated intracranial hemorrhage (ICH) treatment; however, they do not specify goals for time-to-administration. There are limited studies evaluating time to reversal, or international normalized ratio (INR) correction, on hematoma expansion and outcomes in intervals of <4 h. The purpose of this study was to evaluate the association of 4-factor prothrombin concentrate (4F-PCC) time-to-administration on rates of achieving effective hemostasis, determined by hematoma expansion, for treatment of warfarin-associated ICH. METHODS: This was a retrospective, observational, single center study performed at a large community teaching hospital. Patients were stratified into three groups based on time of CT diagnosis of ICH to administration of 4F-PCC: <45 min, 45-90 min, and >90 min. The primary outcome was rates of achieving effective hemostasis in each group defined as a ≤20% increase in hematoma volume as estimated by a radiologist. RESULTS: A total of 227 patients were screened for inclusion with ultimately 39 being included. Baseline characteristics were similar between groups. The primary outcome was not significantly different among groups stratified by time to 4F-PCC administration of <45 min, 45-90 min, and >90 min (85.7% vs 73.3% vs 90%, p value 0.514). There was no difference among secondary outcomes between groups including in-hospital mortality, hospital length of stay (LOS), and intensive care unit LOS. CONCLUSION: There was no association with time-to-administration of 4F-PCC on rates of hemostasis achievement, defined as hematoma expansion of ≤20%, identified in this study.

Spontaneous rectal sheath bleed while on DOAC anticoagulation.

A man in his 80s was transferred from his nursing home residence with sudden onset right-sided abdominal pain. The nursing home staff reported that he was walking to the bathroom when he became diaphoretic, reported he was feeling unwell, then sat on the ground and was reluctant to move. Past medical history was significant for longstanding atrial fibrillation for which he was taking apixaban 2.5 mg twice daily. A CT scan of the abdomen and pelvis was performed which showed a 21×11 cm rectus sheath haematoma on the right extending into the lumbar region. Surgical review advised no invasive intervention. Two units of red cell concentrate were transfused and he was monitored for 5 days before being transferred back to the nursing home.

Efficacy of atorvastatin administration after surgery in patients with chronic subdural hematoma.

To explore the clinical efficacy of atorvastatin administration after surgery in patients with chronic subdural hematoma. We conducted a retrospective study to analyze the clinical data of patients with chronic subdural hematoma. Patients receiving atorvastatin treatment after surgery were divided into the study group while others were divided into the control group. As the primary outcome, we compared the hematoma recurrence rate. The secondary outcomes were the remaining volume of hematoma and the activities of daily living (Barthel index) score at 3 months after discharge. A total of 53 patients were included in the study: 30 patients in the study group (n = 30) and 23 patients in the control group (n = 23). The baseline clinical data were similar in the 2 groups (P > .05). Four patients had recurrence of hematoma in the study group, while 5 patients had recurrence of hematoma in the control group [4/30 (13.3%) versus 5/23 (21.7%), P = .661] at 3 months after discharge. The mean remaining volume of hematoma was 12.10 ±â€…8.80 mL in the study group and 17.30 ±â€…9.50 mL in the control group at 3 months after discharge, respectively. The remaining volume of hematoma in the study group was less than that in the control group (P = .045).The activities of daily living score in the study group were higher than those in the control group (97.83 ±â€…4.48 vs 94.78 ±â€…5.73, P = .034) at 3 months after discharge. Atorvastatin administration after surgery barely reduce the recurrence rate of chronic subdural hematoma, however, reduced the remaining volume of hematoma and improved neurological function.

Clinical characteristics and dynamic evaluation of hematoma morphology in patients with aspirin-related intracerebral hemorrhage.

OBJECTIVE: With the increasing awareness of thrombotic disease prevention and treatment, as well as advancements in cardiac valve replacement and cardiovascular disease resection surgeries, patients undergoing these procedures require antithrombotic medications. This work aimed to explore the dynamic changes in hematoma morphology and volume in aspirin-related intracerebral hemorrhage (ARICH). PATIENTS AND METHODS: 43 cases with ARICH were selected as the experimental group and 40 cases of non-antithrombotic drug-related cerebral hemorrhage (non-ATT-ICH) were enrolled in the control group. General information about the two study groups was collected, and the initial laboratory test indices upon admission for each patient were recorded. Hematoma volumes were recorded within 6 hours, 24±3 hours, 72 hours, and 7 days after the onset of the disease. Volume changes were observed, and the absorption rates of the hematoma at 1 day, 3 days, and 7 days after onset were calculated. RESULTS: In the baseline data, the baseline hematoma volume of the experimental group (19.37±3.21) was slightly higher than that of the control group (15.73±2.78), showing a statistically significant difference (p<0.05). In terms of hematoma morphology and location, the hematoma morphology irregularity of the experimental group compared with the control group was 67% vs. 40%. In terms of hematoma growth and expansion, patients with ARICH had a larger volume of hematoma growth within 1 to 3 days of onset. At 3 d and 7 d, the experimental group's absorption rate was higher than the control group, and the experimental group's hematoma absorption rate was faster than the control group. The experimental group's hematoma morphology was mostly irregular, as can be seen (67%). If the hematoma volume increased from 1 d to 3 d after the onset of the disease, the hematoma volume of the patients in the experimental group was larger. The hematoma absorption rate of the experimental group was faster than that of the control group from 72 h to 7 d. CONCLUSIONS: The morphology of ARICH hematoma was mainly irregular (67%). In ARICH patients, if the hematoma volume rose within 1-3 days of initiation, the hematoma volume increased even more. Compared with non-ATT-ICH, ARICH had a faster rate of hematoma absorption at 3-7 d.

[Iliopsoas muscle hematoma after anticoagulant therapy for pyogenic thrombophlebitis that spilled over from ascending colon diverticulitis:a case report].

A 79-year-old male patient presented to our hospital with chief complaints of fever, abdominal pain, and jaundice. Laboratory data revealed marked hepatobiliary enzyme and inflammatory marker elevations, and computed tomography revealed ascending colon diverticulitis, thrombophlebitis, portal vein thrombus, and intrahepatic cholangitis. Blood culture revealed the presence of Prevotella sp. The patient was treated with anticoagulant therapy in addition to antimicrobial therapy;however, activated partial thromboplastin time prolongation remained insufficient. Antithrombin therapy was combined with the current therapy because antithrombin levels were low, which resulted in iliopsoas muscle hematoma. The hematoma resolved conservatively after discontinuing anticoagulation, and the patient was discharged after 19 days of hospitalization with improved cholangitis and diverticulitis. The portal vein thrombus remained after discharge;however, anticoagulation therapy was not restarted due to adverse events. This case was presented because of its difficult treatment.

Rectus Sheath Hematoma in a Patient with Dual-Antiplatelet Therapy Including Ticagrelor: A Case Report.

Rectus sheath hematoma (RSH) is an uncommon cause of abdominal pain associated with several risk factors including trauma, asthma, chronic obstructive pulmonary disease, pregnancy, and anticoagulation as it can be iatrogenic. Dual-antiplatelet therapy (DAPT), combined usage of a P2Y12 receptor inhibitor and aspirin, is a cornerstone treatment for patients with acute coronary syndromes. Ticagrelor is a P2Y12 receptor inhibitor with several adverse hemorrhagic complications. An 86-year-old male patient was admitted to the emergency department with abdominal pain and a palpable abdominal mass at the left upper quadrant of the abdomen. His medical history revealed coronary artery disease with medications including acetylsalicylic acid and ticagrelor. Contrast-enhanced abdominal computed tomography revealed RSH. The patient was treated conservatively with bed rest and analgesia. DAPT is an essential component of the management of acute coronary syndromes to prevent recurrent cardiac thrombotic events. However, hemorrhagic complications such as RSH may be encountered with DAPT. Emergency medicine physicians and cardiologists should keep in mind RSH in patients presenting with abdominal pain and using DAPT with ticagrelor.

[Operative treatment of distal radial fractures under vitamin K antagonist or DOAC : Is preoperative interruption of these drugs necessary?] / Die operative Versorgung distaler Radiusfrakturen unter Marcumar oder DOAC : Ist ein präoperatives Absetzen der Medikation erforderlich?

BACKGROUND: Scientific data on emergency operations during ongoing treatment with vitamin K antagonists or with direct oral anticoagulants (DOAC) are lacking, because interruption or bridging of this treatment is routinely performed for up to several days. To reduce time delays and to simplify this procedure, we perform operations of distal radial fractures immediately and without interruption of antithrombotic medication. MATERIAL AND METHODS: For this retrospective and monocentric study, we included only patients with distal radial fractures treated within 12 h after diagnosis with open reduction and volar plating and who received anticoagulation with a vitamin K antagonist or DOAC. Primary aim of the study was evaluation of specific complications, such as revision due to bleeding or hematoma formation and secondary aims were thromboembolic events or infections. The endpoint was 6 weeks after the operation. RESULTS: Between 2011 and 2020, 907 consecutive patients with distal radial fractures were operatively treated. Of these, 55 patients met the inclusion criteria. The mean age was 81.5 Jahre (63-94 years) and women (n = 49) were primarily affected. All operations were performed without tourniquets. With a study endpoint 6 weeks after operation, no revisions were performed for bleeding, hematoma, or infection and primary wound healing was assessed for all patients. One revision was performed for fracture dislocation. Thromboembolic events were also not documented. CONCLUSION: In this study the treatment of distal radial fractures within 12 h and without interruption of antithrombotic treatment was not associated with any imminent systemic complications. This applies to both vitamin K antagonists and DOAC; however, higher case numbers must confirm our results.

Retroperitoneal Hematoma During Prophylactic Dose of Heparin Therapy for Coronavirus Disease 2019.

We report a case of retroperitoneal hematoma during prophylactic heparin therapy for coronavirus disease 2019 (COVID-19). A 79-year-old man was diagnosed with COVID-19 pneumonia with possible exacerbation of fibrotic hypersensitivity pneumonia. He received a prophylactic dose of subcutaneous heparin therapy, methylprednisolone pulse therapy and Intravenous remdesivir but developed a spontaneous iliopsoas muscle hematoma, and transcatheter arterial embolization was performed. Even with a prophylactic dose of subcutaneous heparin therapy, the course should be carefully monitored, especially in patients with preexisting risk factors for hemorrhagic complications. Once retroperitoneal hematoma develops, aggressive procedures, such as transcatheter arterial embolization, should be considered to avoid fatal outcomes.

Percutaneous thrombin injection under contrast-enhanced ultrasound guidance to control active extravasation not associated with pseudoaneurysm.

The technique of percutaneous thrombin injection (PTI) under contrast-enhanced ultrasound (CEUS) guidance for control of acute hemorrhage-active extravasation not associated with pseudoaneurysm is demonstrated in three cases: 1) Massive spontaneous retroperitoneal hematoma in a patient with multiple comorbidities. Contrast-enhanced computed tomography (CT) showed extensive active extravasation, which was only partially controlled by transarterial embolization. CEUS was performed in the angiography suite. Contrary to unenhanced US and colour Doppler US (CDUS), CEUS confirmed persistent extravasation; CEUS-guided PTI was performed immediately thereafter. 2) Large rectus sheath hematoma in a patient on anticoagulant therapy. Contrast-enhanced CT and unenhanced US/CD could not definitely diagnose extravasation. CEUS clearly showed extravasation and was used for guidance of PTI. 3) Chest wall hematoma complicating central venous catheter placement in a patient with coronavirus on anticoagulant therapy. CDUS was inconclusive. CEUS was performed at the bedside, clearly showed active extravasation, and was used for guidance of PTI. In all three cases, post-PTI CEUS confirmed the absence of residual enhancement of the hematomas, and the hemodynamic status of the patients improved. PTI appears to be effective in selected cases of hematomas associated with active extravasation. In this context, CEUS may be the most suitable modality for guidance and for an immediate evaluation of the treatment effect.

Spontaneous duodenal hematoma: a rare complication of triple antithrombotic therapy case report.

Triple therapy is defined as concurrent use of an anticoagulant and dual antiplatelet therapy. We aimed to review the clinical course of a patient who developed a spontaneous duodenal hematoma on triple therapy and appraise current guidelines regarding triple antithrombotic therapy use. A 59-year-old man presented with acute heart failure and an apical mural thrombus. After medical stabilization, the patient underwent elective coronary stent placement. He was placed on triple antithrombotic therapy and subsequently developed a spontaneous duodenal hematoma. This case describes a rare but potentially fatal complication of triple therapy and underscores the importance of underutilizing this therapy. In conclusion, we report the clinical presentation and management of a rare bleeding complication in a patient on triple therapy.

The use of multiple types of blood-thinning medications is common in patients with blood clots, atrial fibrillation and heart disease, which can increase their risk of bleeding. We present the case of a rare type of gastrointestinal bleeding (a spontaneous duodenal hematoma) that occurred shortly after a patient with new heart failure and a blood clot in the left ventricle was placed on three different types of blood-thinning medications following a cardiac stent procedure. This case highlights the importance of careful management of comorbid cardiac conditions as well as the avoidance of using three blood-thinning medications simultaneously.