Download Iliopsoas haematoma - Hong Kong College of Emergency Medicine

Hong Kong Journal of Emergency Medicine
Iliopsoas haematoma: an uncommon differential diagnosis for groin pain
GPH Choa and CS Lim
Bleeding complications should be considered in the differential diagnosis of any patient on warfarin therapy.
A 66-year-old man presenting with right groin pain due to a spontaneous iliopsoas hematoma is reported.
Computed tomography of the abdomen and pelvis at the emergency department confirmed the diagnosis.
Fresh frozen plasma was given to correct the clotting derangement. The patient was managed conservatively.
He was subsequently discharged well without complication. Iliopsoas haematoma or spontaneous
retroperitoneal haemorrhage is an uncommon complication that needs to be considered in the differential
diagnosis of a patient on warfarin therapy with abdominal, flank or groin pain. (Hong Kong j.emerg.med.
2011;18:173-176)
warfarin
66
warfarin
Keywords: Coagulation disorder haemorrhage, retroperitoneal, warfarin
Case report
A 66-year-old man presented to the emergency room
complaining of right groin pain and right lower back
pain for three days. The pain started shortly after
playing a game of golf three days earlier. The groin
and back pain was getting progressively worse and was
exacerbated by ambulation and movement of the right
hip. The patient could not recall any specific incident
of back injury or trauma and he did not have a history
of back pain. There was no sciatica or neurological
Correspondence to:
Choa Peng Hui, Gary, MBBS, MMed, MRCS(Edin)
Singapore General Hospital, Department of Emergency
Medicine, 1 Outram Road, Singapore 169608
Email: [email protected]
Lim Chin Siah, MBBS, MMed, MCEM
complaint involving the lower limbs. No bladder or
bowel symptoms were reported. There was no
abdominal pain. The patient also denied a history of
urinary calculus.
The patient had a history of sick sinus syndrome
treated with pacemaker insertion. He was on warfarin
for atrial fibrillation. He also had acute myeloid
leukaemia four years ago. He had been in remission
after chemotherapy.
The patient was comfortable at rest. Vital signs were
normal. The abdomen was soft and non-tender. No
pulsatile mass was detected and both femoral pulses
were equal. The kidneys were not ballotable and there
was no loin tenderness. There was no hernia and the
scrotal contents were normal. The anal tone was good
and there was no saddle anaesthesia. The neurological
examination of the lower limbs was normal.
174
Hong Kong j. emerg. med. „ Vol. 18(3) „ May 2011
The patient was able to bear weight and ambulate with
an antalgic gait. Forward flexion of the lumbar spine
was normal but there was back pain on extension.
Straight leg raising was full but the patient did
complain of pain when the limb was being lowered.
The range of movement of the right hip was full but
again there was pain on extension of the right hip.
warfarin dosage and the patient claimed to have good
compliance to his medications. However the INR in
the emergency room (ER) was markedly elevated
to 8.09. The full blood count also revealed a drop in
haemoglobin from 13.1 g/dl to 12 g/dl over the past
one month. Systemic enquiry did not reveal any source
of bleeding that explained the drop in haemoglobin.
Bedside urine dipstix analysis did not show any red
blood cells or leukocytes. Ultrasonography of the
abdomen was done. The abdominal aorta was not
enlarged and there was no free fluid in the abdomen.
The renal outlines were normal and there was no
hydronephrosis. X-ray examination of the lumbar spine
and pelvis revealed mild degenerative changes in both
hip joints and lumbar spine and that of the kidney,
ureter and bladder did not show any radioopaque
calculus. However the right psoas shadow was obscured
(Figure 1).
A non-contrast computed tomography of the abdomen
and pelvis was done at the ER. A 7.4 x 3.6 cm
retroperitoneal haematoma in the right posterior
pararenal space was found (Figure 2). There was also a
right iliopsoas haematoma extending inferiorly to the
thigh (Figure 3).
His international normalised ratio (INR) was 2.6 one
month ago. There was no recent adjustment to the
Figure 2. CT abdomen image shows a right posterior para-renal
collection (arrow) consistent with retroperitoneal haemorrhage.
Figure 3. CT abdomen image shows an isodense swelling of the
Figure 1. X-ray showing an ill-defined right psoas shadow (the
right iliacus (big arrow) and psoas muscle (small arrow) consistent
left psoas shadow is well seen and indicated with arrows).
with a haematoma.
Choa et al./Iliopsoas haematoma
The patient was given fresh frozen plasma to correct
his deranged coagulation profile and warfarin was
discontinued. The retroperitoneal haematoma was
treated conservatively. The patient was discharged 3
days later with a stable haemoglobin level and an INR
of 3.5. The groin pain had resolved. Computed
tomography was not repeated prior to discharge.
Further inquiry showed that the patient had been
taking off-the-counter anti-oxidant supplements for
one month before presentation. The patient was
reminded on the risks of over-anticoagulation and was
advised against taking medications or supplements
without consulting a physician.
Discussion
Patients often present with undifferentiated symptoms
to the emergency department. Thorough history
taking, careful clinical examination and consideration
of relevant differential diagnoses are important.
Although common diagnoses occur commonly,
unusual but potentially life threatening causes must
also be considered and excluded. This case illustrates
an uncommon cause of a common complaint.
For this patient who presented with right groin pain,
differential diagnoses initially considered included
ureteric colic, hernia, lumbar spondylosis with sciatica,
abdominal aortic aneurysm and aortic dissection. Each
was however in turn excluded through a combination
of physical examination and bedside, radiological and
laboratory investigations. In our patient, a grossly
deranged INR and a drop in haemoglobin without
overt bleeding prompted the request for a computed
tomography of the abdomen to rule out retroperitoneal
bleeding as a cause of his groin pain.
Warfarin produces its anticoagulation effects by
interfering with the vitamin K dependent carboxylation
of prothrombin. It is used in various conditions such
as atrial fibrillation, post mechanical valve replacement,
and treatment and prevention of thromboembolic
events. Bleeding complications associated with warfarin
use include gastrointestinal and intracranial bleeds,
175
rectus sheath haematomas and retroperitoneal
haematomas. It has been reported that 1-7% of patients
taking anticoagulants will suffer a bleeding
complication each year.1
Iliopsoas haematomas uncommonly occur secondary
to trauma due to the deep seated location of the
muscles. Spontaneous iliopsoas haematomas are
relatively more common and usually occur in patients
with coagulopathy either due to haemophilia or
anticoagulant therapy from warfarin or enoxaprin. 2
Bilateral iliopsoas haematomas are also described in
literature. 3 Liver cirrhosis as a cause of spontaneous
iliopsoas haematoma has also been reported. 4 There
was one case report of a haematoma of the iliopsoas
muscle from thrombocytopenia due to a third
generation cephalosporin. 5 Muscular sprain from
exertion, as in our patient, is an identified cause.
However, there was a case report on a spontaneous
iliopsoas haematoma in a patient who was neither on
anticoagulant therapy nor suffering from a
coagulopathy.6
Iliopsoas haematomas typically present with groin or
thigh pain. Abdominal or flank pain may be present
when there is retroperitoneal extension.7 Ecchymoses
in the peri-umbilical area (Cullen's sign) or in the
flanks (Grey-Turner's sign) may occur. 8 Large
retroperitoneal bleeding may cause hypovolaemic
shock. Compressive femoral neuropathy may occur in
cases where the haematoma in the iliacus or psoas
muscle is large enough to compress the femoral nerve
as it passes through these muscles. 9,10 This usually
presents as acute unilateral lower limb sensory
numbness or paraesthesia. Muscle weakness may be
present in chronic or more severe cases. Typically the
hip is flexed in the involved side and pain is elicited
on passive extension as the iliopsoas muscle is stretched.
Compression of the ureter may cause hydronephrosis
and acute renal failure may occur if the compression is
bilateral. Compression of the inferior vena cava has
also been reported to cause deep vein thrombosis.11
Ultrasonography has been used to diagnose iliopsoas
haematomas but its sensitivity and specificity are user-
176
dependent and it is also technically difficult due to
the deep seated location of the muscle and obscuration
by the ilium. Magnetic resonance imaging is the
investigation of choice. Computed tomography is more
readily accessible and is adequate for diagnosis of
intramuscular and retroperitoneal haematomas.
Treatment of spontaneous retroperitoneal haematoma
is usually conservative as in our case. The deranged
clotting profile may be corrected by fresh frozen plasma
or vitamin K. Supportive measures with blood
transfusion may be necessary. The INR, haemoglobin
level and clinical symptoms should be monitored.
Surgical decompression may be indicated in
compressive femoral neuropathy.12
Warfarin is well known to interact with many
medications which interfere with its metabolism and
increase the risk of over-anticoagulation. Medical
literature is also replete with case reports of various
substances that may interact with warfarin. Physicians
should be alert to the potential interactions with
polypharmacy in patients on warfarin therapy. It may
also be dangerous when patients take off-the-counter
medications or health supplements. A thorough review
of the patient's drug history and exclusion of self
medication is thus important. Patients on warfarin
should be reminded of this potential complication.
Spontaneous retroperitoneal haematoma in patients
who are on warfarin therapy is uncommon and has
been described in literature. This case serves as a timely
reminder that atypical presentations and uncommon
causes must be considered in any patient on warfarin
therapy. In particular, abdominal, flank, groin or
thigh pain should trigger suspicion of an iliopsoas
haematoma and retroperitoneal bleeding.
Hong Kong j. emerg. med. „ Vol. 18(3) „ May 2011
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Beyth RJ. Management of haemorrhagic complications
associated with oral anticoagulant treatment. Expert
Opin Drug Saf 2002;1(2):129-36.
Dauty M, Sigaud M, Trossaert M, Fressinaud E,
Letenneur J, Dubois C. Iliopsoas hematoma in patients
with hemophilia: a single-center study. Joint Bone Spine
2007;74(2):179-83.
Marquardt G, Barduzal Angles S, Leheta F, Seifert V.
Spontaneous hematoma of the iliac psoas muscle: a case
report and review of literature. Arch Orthop Trauma
Surg 2002;122(2):109-11.
Sugiyama C, Akai A, Yamakita N, Ikeda T, Yasuda K.
Muscle hematoma: a critically important complication
of alcoholic liver cirrhosis. World J Gastroenterol 2009;
15(35):4457-60.
Onodera M, Fujino Y, Inoue Y, Kikuchi S, Endo S.
Hematoma of the iliopsoas muscle due to
thrombocytopenia resulting from the administration of
a third generation cephalosporin. Ann Hematol 2010;
89(8):825-6.
Wada Y, Yanagihara C, Nishimura Y. Bilateral iliopsoas
hematomas complicating anticoagulant therapy. Intern
Med 2005;44(6) 641-3.
Kwon OY, Lee KR, Kim SW. Spontaneous iliopsoas
muscle haematoma. Emerg Med J 2009;26(12):863.
Morgan RJ, Bristol JB. Unusual findings in a patient
taking warfarin. Postgrad Med J 1999;75(883):299-300.
Jamjoom ZA, al-Bakry A, al-Momen A, Malabary T,
Tahan AR, Yacub B. Bilateral femoral nerve compression
by iliacus hematomas complicating anticoagulant
therapy. Surg Today 1993;23(6):535-40.
Ong HS. Compressive femoral neuropathy: a rare
complication of anticoagulation. Singapore Med J 2007;
48(3):e94-5.
Phillips S, Barr A, Wilson E, Rockall TA, Stebbing JF.
Two cases of retroperitoneal haematoma caused by
interaction between antibiotics and warfarin. Emerg
Med J 2006;23(1):e8.
Nakao A, Sakagami K, Mitsuoka S, Uda M, Tanaka N.
Retroperitoneal hematoma associated femoral
neuropathy: a complication under antiplatelet therapy.
Acta Med Okayama 2001;55(6):363-6.