P2667 - Anti-Coagulation-Induced Mesenteric Hematoma Presenting as Small Bowel Obstruction

Richa Dua, MBBS¹, Jayasree Ravilla, MD², Apurva Ketkar, MD¹, Medha Ghose, MD¹, Husam Bader, MD^1
1Monmouth Medical Center, Long Branch, NJ; ²Monmouth Medical Center/RWJBH, Long Branch, NJ

Introduction: Bleeding complications like hematomas in the intracranial, pectoral and spinal regions have been reported with anticoagulant use. Mesenteric hematoma is one of the rare complications. We present an unusual case of spontaneous mesenteric hematoma after apixaban and clopidogrel use, presenting as small bowel obstruction.

Case Description/Methods: A 71-year-old female with a history of asthma and aspirin allergy presented with fever, pleuritic right sided chest pain, productive cough and new onset atrial fibrillation. A CT-scan of the chest, abdomen and pelvis performed upon admission revealed right lower lung lobe pneumonia with a small loculated pleural effusion, without any findings in the abdomen at that time. Pneumonia was managed with intravenous fluids and antibiotics. New onset AF was managed with intravenous diltiazem. On the very first day of hospitalisation she had converted back to normal sinus rhythm. Clopidogrel (given aspirin allergy) was initiated for secondary prevention of cardiovascular disease, based on expert recommendation. On day 2 of hospitalisation she went back into AF. At this time apixaban was added to her regimen along with initiation of intravenous amiodarone. In the morning of Day 3, she reported severe nausea, multiple episodes of emesis overnight and abdominal pain. Her abdomen was found to be distended with no bowel sounds. CT scan of the abdomen revealed a new moderate sized hemoperitoneum with an evolving mesenteric hematoma in the anterior pelvis measuring 4x4x3.1 cm along with small bowel obstruction (SBO), with transition point in the right lower quadrant of the abdomen and collapsed bowel loops distally, from the hematoma. Antiplatelet and anticoagulation was held and the patient was managed conservatively for her SBO and hematoma.

Discussion: Commonly reported adverse effects with clopidogrel are nausea, diarrhoea and constipation. Both antiplatelet as well as anticoagulants increase the risk of bleeding in all individuals. Cases of spontaneous intracranial, pectoral and spinal regions have been reported with apixaban and clopidogrel. However, occurrence of spontaneous mesenteric hematoma causing small bowel obstruction is rare. Through our case we would like to encourage healthcare providers to think about this possible adverse effect in patients developing signs and symptoms consistent with SBO while they are being treated with clopidogrel, apixaban or both.



Disclosures:


Richa Dua, MBBS¹, Jayasree Ravilla, MD², Apurva Ketkar, MD¹, Medha Ghose, MD¹, Husam Bader, MD¹. P2667 - Anti-Coagulation-Induced Mesenteric Hematoma Presenting as Small Bowel Obstruction, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.