Prophylaxis with enoxaparin can produce a giant abdominal wall haematoma when associated with low doses of aspirin among elderly patients suffering cough attacks

Abstract

We report three patients aged 75-80 years observed in the Emergency Room with severe anaemia (requiring transfusion) due to a large abdominal wall haematoma while receiving standard prophylaxis against venous thromboembolism (40 mg/day enoxaparin for 6 days on average). All of them concomitantly received 100 mg/day aspirin because of previous ischaemic heart disease and presented similar clinical features: sudden onset of abdominal pain during a severe cough episode due to bronchial infection. A giant haematoma in the rectus abdominis muscle was recognized (by computed tomography) in every case. The cough has been related with this complication in some reports but its association with antiplatelet drugs and low molecular weight heparin could increase the risks in older patients. Sudden abdominal pain must alert the clinician to the rectus muscle sheath haematoma in order to avoid the risks of an exploratory laparotomy.

Evaluation of Risk Factors for Rectus Sheath Hematoma

“…Nonsurgical trauma especially due to coughing or strenuous exercise is attributed to RSH formation in multiple cases. 6,7,16,17 One-third of our patients had coughing episodes. Coughing paroxysm can cause severe contractions of the abdominal muscles which can injure the epigastric vessels or the rectus muscle itself.…”

Splenectomy complicated by sustained extreme thrombocytosis and extensive portosplenomesenteric vein thrombosis in pyrimidine 5′-nucleotidase deficiency

“…In such situations a high index of suspicion is necessary for early diagnosis and prompt anticoagulation for successful outcome 16. Prophylaxis for thrombosis is usually by enoxaparin 40 mg for 6 days on average 17. In this patient although prophylactic anticoagulation was given for a longer time, extensive PSMVT nevertheless had occurred.…”

Fatal haemorrhage associated with enoxaparin

“…It has been postulated that atrophy of the cutaneous and s.c. periumbilical tissues may predispose patients to the development of haematomas. 3 One published case study has shown, through aortic iliac and pelvic arteriography, that needle puncture of the inferior epigastric artery may have been a contributing factor to the occurrence of a rectus sheath haematoma in a patient receiving therapeutic doses of enoxaparin. 4 Cachectic and elderly patients with advanced periumbilical tissue atrophy are the primary cohort at risk, but clinicians should also be suspicious of males with central obesity.…”