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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 4  |  Page : 298-300

Spontaneous abdominal hemorrhage due to warfarin treatment


1 Department of Internal Medicine, Malatya State Hospital, Malatya, Turkey
2 Department of Emergency Medicine, Faculty of Medicine, Inonu University, Malatya, Turkey
3 Department of Internal Medicine, Rize Findikli State Hospital, Rize, Turkey
4 Department of Internal Medicine Clinic, Sakarya Research and Education Hospital, Sakarya, Turkey

Date of Web Publication14-Sep-2016

Correspondence Address:
Dr. Mustafa Volkan Demir
Department of Internal Medicine, Malatya Government Hospital, Malatya
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.190571

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  Abstract 

Warfarin is an anticoagulant used in the prevention of thromboembolism. Common clinical indications for warfarin use are atrial fibrillation, artificial heart valves, deep venous thrombosis. Common side effect of warfarin is hemorrhage. Intra-peritoneal hemorrhage is one of the complications, usually following trauma. We report spontaneous intra-abdominal hemorrhage secondary to warfarin therapy. A 79 year-old male patient was admitted to emergency clinic with the complaints of one day duration of abdominal pain. There was no history of trauma. He had been on warfarin for the prophylaxis of atrial fibrillation.The diagnosis of the spontaneous intra-abdominal bleeding secondary to warfarin was made and the patient was admitted internal medicine inpatient clinic.This case provides a learning lesson to the physicians to consider this rare but significant complication of warfarin in the differential diagnosis of all the cases of abdominal pain in patients who are on warfarin therapy.

Keywords: Abdominal hemorrhage, abdominal pain, warfarin


How to cite this article:
Demir MV, Demir TÖ, Yaylaci S, Genc AB. Spontaneous abdominal hemorrhage due to warfarin treatment. CHRISMED J Health Res 2016;3:298-300

How to cite this URL:
Demir MV, Demir TÖ, Yaylaci S, Genc AB. Spontaneous abdominal hemorrhage due to warfarin treatment. CHRISMED J Health Res [serial online] 2016 [cited 2020 Apr 7];3:298-300. Available from: http://www.cjhr.org/text.asp?2016/3/4/298/190571


  Introduction Top


Warfarin is an anticoagulant used in the prevention of thrombosis. Warfarin decreases blood coagulation by inhibiting Vitamin K epoxide reductase, an enzyme that recycles oxidized Vitamin K1 to its reduced form after it has participated in the carboxylation of several blood coagulation proteins, prothrombin, and factor VII.[1] Common clinical indications for warfarin use are atrial fibrillation, artificial heart valves, and deep venous thrombosis.[2] Common side effect of warfarin is hemorrhage. Intraperitoneal hemorrhage is one of the complications, usually following trauma. There are only very few reported cases of the spontaneous hemoperitoneum in the literature.[3] Spontaneous onset of the intra-abdominal hemorrhage due to warfarin therapy is also exceptional. We report spontaneous intra-abdominal hemorrhage secondary to warfarin therapy.


  Case Report Top


A 79-year-old male patient was admitted to emergency clinic with the complaints of 1-day duration of abdominal pain. The pain was constant and dull in the periumbilical region, which later became localized in the right abdomen. There was no history of trauma. He had been on warfarin for the prophylaxis of atrial fibrillation. He used to take pantoprazole, metoprolol, ramipril as his regular medications. Blood pressure was 130/80 mmHg, heart rate was 110/min, and temperature was 36.8°C in the admission. There was no hematoma in the abdominal wall. There were guarding in the right iliac fossa. The rectal examination was normal. The urine analysis was normal. The blood analysis showed hemoglobin of 7.9 g/dl with reduced hematocrit of 23.5%, white blood cells of 14.7 × 109/l, and international normalized ratio (INR) of 6.12. Ten centimeters hematoma in the right psoas muscle and 4 cm hematoma in the right mesenteric area were shown with the abdominal ultrasonography. The ultrasonographic findings were compatible with acute hematoma. The diagnosis of the spontaneous intra-abdominal bleeding secondary to warfarin was made, and the patient was admitted internal medicine inpatient clinic. Warfarin treatment was stopped. Three units of fresh frozen plasma and 3 units of erythrocyte suspension were transfused. An amount of 20 mg Vitamin K was given intravenously. Complete blood count, INR, blood tension, and rate were monitored. There was no sign of active bleeding. The blood analysis showed hemoglobin of 10 g/dl, hematocrit of 30.5%, white blood cells of 9.78 × 109/l, and INR of 1.26 on the 2nd day of admission. Warfarin treatment was started on the 3rd day of admission. At 6 days follow-up visit in the clinic, the patient was doing well without any complaints and complications. The INR was 2.3 on the 6th day of admission.


  Discussion Top


Warfarin is associated with the serious adverse effects such as the hematuria, soft tissue bleeding and hematoma, intracerebral hemorrhage, gastrointestinal hemorrhage, and abdominal hemorrhage.[4] Abdominal hemorrhage was occurred in our case. In patients treated by oral anticoagulants and suffering from abdominal pain, spontaneous intra-abdominal hemorrhage should be systematically searched. Diagnosis can be achieved using ultrasound (like the present case). Ultrasonographic examination is interesting because it is cost-effective, easily, immediately accessible, and with high levels of sensitivity. The more frequently computed tomography is also performed because it is a better imaging method compared to ultrasound in assessing the location and size of hematomas. We did not need to perform computed tomography.

The HAS-BLED (acronym of the major factors associated with bleeding risk in patients with atrial fibrillation receiving oral anticoagulation) score has been previously reported that the risk of major bleeding among patients with atrial fibrillation was based on the presence of hypertension, abnormal liver or renal function, history of stroke or bleeding, labile INRs, concomitant use of drugs that promote bleeding or excess alcohol use and elderly age (>65 years),[5] Our patient's elderly age, hypertension, and concomitant drug using were risk factors. Consequently, before the prescription of an anticoagulant agent, it is important to assess the risk of bleeding using the HAS-BLED score.

The most important determinant of the warfarin-induced hemorrhage is the intensity of therapy.[6] Bleeding is more likely to occur in the patients with the more intense therapeutic range (INR between 2.5 and 3.5) than in the less intense therapeutic range of warfarin (INR between 2 and 3).[7] Warfarin therapy is associated with a variety of hemorrhagic complications that are usually associated with inadequate control of anticoagulation. Our patient's INR was 6.2. Although it has been shown that there is an increase in the risk of major bleeding as the INR increases, major bleeding can occur at therapeutic levels.

Hemorrhage is a major complication in the early phase of the warfarin therapy according to the most studies. Fihn et al. evaluated 928 patients that were on chronic anticoagulation with warfarin in a retrospective cohort study. They found an incidence of the first bleeding episodes of 17.3 events/100 patient-years for minor bleeding, 7.5 events/100 patient-years for serious bleeding, 1.1 events/100 patient-years for life-threatening bleeding, and 0.2 events/100 patient-years for fatal bleeding.[8]

Spontaneous bleeding is one of the well reported and most common adverse effects of warfarin. The first step in the therapy is to stop the administration of anticoagulant drugs and correct the patient's coagulation parameters with fresh-frozen plasma and Vitamin K as in our case.

The CHADS2 score can help physicians estimate stroke risk in patients with nonvalvular atrial fibrillation and determine which antithrombotic therapy is most appropriate. Congestive heart failure, hypertension, age ≥75 years, diabetes, and stroke/transient ischemic attack history were the risk factors in the CHADS2 score.[9] Elderly age, hypertension, transient ischemic attack history were the risk factors in our case. Our patient's thrombosis risk and re-bleeding risk calculated with CHADS2 score and HAS-BLED score. Our patient was borderline in terms of risk of CHADS2 and HAS-BLED. We decided to initiate warfarin treatment early. This management could be seemed appropriate because of mortality has been associated with early initiation of warfarin after bleeding. Some authors have proposed to withdraw anticoagulant treatment during a short period in only situations involving a high risk of thrombosis. In patients at low risk to thrombosis and at high risk of bleeding a later resumption of anticoagulants might be safer.

This case provides a learning lesson to the physicians to consider this rare but significant complication of warfarin in the differential diagnosis of all the cases of abdominal pain in patients who are on warfarin therapy. We recommend the use of the radiological investigations such as ultrasound in these cases to achieve diagnosis. It is recommended to assess the risk of thrombosis and bleeding using CHADS2 score and HAS-BLED score. The patients and their relatives should be informed about the potential complication of warfarin, and the doses should be explained in detail.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Holbrook AM, Pereira JA, Labiris R, McDonald H, Douketis JD, Crowther M, et al . Systematic overview of warfarin and its drug and food interactions. Arch Intern Med 2005;165:1095-106.  Back to cited text no. 1
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2.
Hirsh J, Fuster V, Ansell J, Halperin JL; American Heart Association/American College of Cardiology Foundation. American Heart Association/American College of Cardiology Foundation guide to warfarin therapy. J Am Coll Cardiol 2003;41:1633-52.  Back to cited text no. 2
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3.
Schattner A, Kozack N, Friedman J. Idiopathic spontaneous hemoperitoneum. Arch Intern Med 2001;161:1009-10.  Back to cited text no. 3
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4.
Morgan RJ, Bristol JB. Unusual findings in a patient taking warfarin. Postgrad Med J 1999;75:299-300.  Back to cited text no. 4
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5.
Lip GY, Frison L, Halperin JL, Lane DA. Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: The HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol 2011;57:173-80.  Back to cited text no. 5
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6.
Singer DE, Albers GW, Dalen JE, Go AS, Halperin JL, Manning WJ. Antithrombotic therapy in atrial fibrillation: The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004;126 3 Suppl: 429S-56S.  Back to cited text no. 6
    
7.
Breen AB, Vaskinn TE, Reikvam A, Skovlund E, Lislevand H, Madsen S. Warfarin treatment and bleeding. Tidsskr Nor Laegeforen 2003;123:1835-7.  Back to cited text no. 7
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8.
Fihn SD, McDonell M, Martin D, Henikoff J, Vermes D, Kent D, et al. Risk factors for complications of chronic anticoagulation. A multicenter study. Warfarin optimized outpatient follow-up study group. Ann Intern Med 1993;118:511-20.  Back to cited text no. 8
    
9.
Yarmohammadi H, Varr BC, Puwanant S, Lieber E, Williams SJ, Klostermann T, et al. Role of CHADS2 score in evaluation of thromboembolic risk and mortality in patients with atrial fibrillation undergoing direct current cardioversion (from the ACUTE Trial Substudy). Am J Cardiol 2012;110:222-6.  Back to cited text no. 9
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