Medical Image of the Week: Abdominal Hematoma

 

Figure 1. Contrast-enhanced CT abdomen/pelvis showing A) coronal and B) sagittal views of a LLQ hematoma (blue braces) with active contrast extravasation (red arrow). Lines represent the level of respective axial images. C-F) Axial images demonstrating the hematoma within and expanding the rectus abdominis sheath (blue braces) as well as active contrast leak (red arrow).

Figure 2. A) Arteriogram demonstrating the large hematoma (solid arrow) with active extravasation of contrast from the inferior epigastric artery (arrowhead) arising from the external iliac artery (empty arrow). B) Coils in the inferior epigastric artery (arrow) block flow to the hematoma.

A 59 year-old man presented to clinic with acute-on-chronic non-productive cough along with sore throat and myalgias for 2 weeks and lower left quadrant (LLQ) abdominal pain for 2-3 days. He was a current smoker with history significant for COPD and mild “smoker’s cough” controlled with daily anticholinergic and as-needed beta-agonist, paroxysmal atrial fibrillation on dabigatran and diltiazem, hypertension controlled by diuretic, and a former alcoholic with hemochromatosis.

While getting an x-ray, he had a coughing fit resulting in abrupt worsening of his LLQ pain enough to inhibit ambulation. Due to his inability to walk, he came via ambulance to the emergency department, where he was mildly tachycardic with a 10cm firm, tender and ecchymotic LLQ mass.

Contrast-enhanced abdominal/pelvic CT demonstrated a large rectus abdominis hematoma. Figure 1 shows the hematoma within the rectus sheath measuring 16 cm with active contrast extravasation. The patient went directly to the interventional suite, where the left inferior epigastric artery was catheterized and subsequently embolized as shown in Figure 2.

The patient was noted to be in atrial fibrillation with rapid ventricular response (AFRVR), so was taken to the intensive care unit and placed on diltiazem drip, given digoxin and 1 unit of RBCs before his rhythm stabilized and he was transferred to the floor. His hemoglobin remained stable, and his cough and abdominal pain improved, so he was sent home off anticoagulation until follow-up with his cardiologist.

In the RE-LY trial, updated in 2010 (1), there was no difference in bleeding complications at this patient’s dosing of dabigatran compared to warfarin with INR of 2.0-3.0. However, this patient did not bleed into a critical area, require 2 units of RBCs, nor drop hemoglobin >2mg/dl, and would thus be considered having a minor bleeding event despite needing emergent embolization, losing enough blood to become tachycardic with resulting AFRVR, and getting 1 unit of RBC

Despite this particular bleeding complication, in a meta-analysis examining dabigatran vs warfarin, dabigatran uniformly was as good or better in preventing strokes with less devastating complications than warfarin (2). Additionally, although warfarin is touted as having vitamin K as its reversal agent, protein synthesis and secretion into the vasculature takes hours, similar in time to metabolically clear dabigatran (3).

In the end, after discussions about anticoagulants with the hospital team before discharge and his cardiologist thereafter, the patient elected to restart his dabigatran.

Michael Larson, M.D., Ph.D.

Banner-University Medical Center

University of Arizona

Medical Imaging Department

Tucson, AZ, USA

References

1. Connolly SJ, Ezekowitz MD, Yusuf S, Reilly PA, Wallentin L; Randomized Evaluation of Long-Term Anticoagulation Therapy Investigators. Newly identified events in the RE-LY trial. N Engl J Med. 2010 Nov 4;363(19):1875-6. [CrossRef] [PubMed]
2. Gómez-Outes A, Terleira-Fernández AI, Calvo-Rojas G, Suárez-Gea ML, Vargas-Castrillón E. Dabigatran, rivaroxaban, or apixaban versus warfarin in patients with nonvalvular atrial fibrillation: a systematic review and meta-analysis of subgroups. Thrombosis. 2013;2013:640723. [CrossRef] [PubMed]
3. Ganetsky M, Babu KM, Salhanick SD, Brown RS, Boyer EW. Dabigatran: review of pharmacology and management of bleeding complications of this novel oral anticoagulant. J Med Toxicol. 2011 Dec;7(4):281-7. [CrossRef] [PubMed]

Cite as: Larson M. Medical image of the week: abdominal hematoma. Southwest J Pulm Crit Care. 2016:13(4): 176-8. doi: http://dx.doi.org/10.13175/swjpcc083-16 PDF

October 2016 Imaging Case of the Month

Michael B. Gotway, MD  

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA 

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Clinical History: A 35-year-old woman presented with a several month history of slowly worsening shortness of breath and dry cough. Laboratory data, include white blood cell count and serum chemistries were within normal limits. Oxygen saturation on room air was 99%.

Frontal and lateral chest radiographs (Figure 1) were performed.

Figure 1. Frontal (A) and lateral (B) radiographs.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of seven panels)

1. Frontal and lateral chest radiography appears normal
2. Frontal and lateral chest radiography shows abnormally diminished lung volumes
3. Frontal and lateral chest radiography shows bilateral peribronchial and mediastinal lymph node enlargement
4. Frontal and lateral chest radiography shows cardiomegaly
5. Frontal and lateral chest radiography shows upper lobe bilateral linear and reticular abnormalities

Cite as: Gotway MB. October 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;13(4): . doi: http://dx.doi.org/10.13175/swjpcc100-16 PDF