Keywords
dual-antiplatelet therapy - hemorrhage - rectus abdominis - ticagrelor
Introduction
Ticagrelor is an oral antiplatelet agent exhibiting its effects by reversibly binding
to platelet ADP P2Y12 receptors to prevent platelet activation and aggregation. Dual-antiplatelet therapy
(DAPT), combined with a P2Y12 receptor inhibitor and aspirin, is a cornerstone treatment for patients with acute
coronary syndromes.[1] Several hemorrhagic complications including intracranial, gastrointestinal, urinary,
pulmonary, retroperitoneal, intra-articular, and subcutaneous bleeding have been reported
with ticagrelor treatment.[2]
Rectus sheath hematoma (RSH) is an uncommon cause of abdominal pain resulting from
accumulated blood within the rectus sheath. It may be seen in up to 1.8% of patients
with abdominal pain.[3] Several risk factors including older age, female sex, trauma, asthma, chronic obstructive
pulmonary disease (COPD), pregnancy, and anticoagulation have been associated with
the formation of RSHs as it can be iatrogenic.[4] In this case report, we present a case of RSH associated with DAPT including ticagrelor.
Case Report
An 86-year-old male patient was admitted to the emergency department with abdominal
pain with a palpable abdominal mass at the left upper quadrant of the abdomen. His
medical history revealed hypertension, coronary artery disease, hypercholesterolemia,
COPD, and no recent trauma or surgery. He has no COPD exacerbations like increased
sputum, cough, or rhonchi in physical examination. His medications were acetylsalicylic
acid 100 mg/day, metoprolol 50 mg twice daily, ramipril 5 mg/day, atorvastatin 40 mg/day,
and ticagrelor 90 mg twice a day due to acute myocardial infarction. One month ago
the patient was diagnosed with acute anteroseptal myocardial infarction and a stent
was implanted into the left anterior descending artery. His vital signs on the current
admission were temperature: 36.5 °C, heart rate: 78 beats/min, blood pressure: 140/80 mm
Hg, and respiration: 16 times per minute. His physical examination revealed a palpable
and tender abdominal mass in the left upper quadrant of the abdomen. Laboratory results
were hemoglobin: 11.9 g/dL, platelets: 184,000/mL, activated partial thromboplastin
time: 30.6 seconds, and prothrombin time: 12.5 seconds (INR: 1.1). Contrast-enhanced
abdominal computed tomography (CT) revealed a hematoma in 5 × 3 cm dimensions in the
left rectus sheath ([Fig. 1]). The patient's status remained hemodynamically stable without any significant change
in vital signs, and serially measured hemoglobin and hematocrit levels did not decrease
during the follow-up in the emergency department. Therefore, DAPT was not withheld.
He was treated conservatively with bed rest, ice compression, and analgesia. After
3 days of follow-up in the emergency department, the patient was discharged with recommendations
such as bed rest, and analgesia and told to admit to the emergency department if the
hemorrhagic mass might expand. There was no admission about the complication during
the next month.
Fig. 1 Contrast-enhanced abdominal computed tomography finding of left rectus sheath hematoma
(arrow).
Discussion
RSH may mimic a range of acute abdominal pathologies, requiring increased suspicion,
timely diagnostic evaluation, and management. RSH often presents as acute abdominal
pain with a palpable mass. Patients may also present with signs of hypovolemic shock
based on the amount of bleeding. The diagnosis of RSH can be confirmed by either ultrasonography
or abdominopelvic CT. Abdominopelvic CT reveals accurate information about the location,
size, and extension of the RSH.[4]
[5] Abdominopelvic CT has excellent sensitivity and specificity in terms of diagnosis
of RSH and is useful for excluding other abdominal pathologies.[4]
Management of RSH is determined by the patient's clinical status, the underlying cause
of the RSH, and the severity of the RSH. A vast majority of patients are hemodynamically
stable and treated conservatively with analgesia, bed rest, compression of the hematoma,
and reversal of anticoagulation when appropriate. Packed red blood cells and appropriate
blood products should be transfused if necessary. As Warren et al emphasized, patients
with hypovolemic shock should be resuscitated aggressively and promptly referred for
either angiography or surgery to control the source of bleeding.[4]
[6]
Anticoagulation therapy and antiplatelet therapy are common risk factors reported
for RSH.[7]
[8] In the retrospective study of Sheth et al (n = 114), warfarin (n = 42), unfractionated heparin (n = 37), low-molecular-weight heparin (n = 17), and antiplatelet therapy—aspirin or clopidogrel—(n = 34) were the most causative agents for RSH.[7] Several cases of RSHs have been reported due to DAPT consisting of aspirin and clopidogrel.[7]
[9] DAPT including ticagrelor provides a stronger antithrombotic effect, although rare
bleeding conditions such as omental bleeding, hepatic subcapsular hematoma, and RSH
may be encountered with DAPT.[10]
[11] Furthermore, a case of multifocal muscular bleeding during DAPT including aspirin
and ticagrelor has been reported.[12] To the best of our knowledge, our case is the first report of isolated RSH in a
patient using DAPT including ticagrelor.
Conclusion
RSH may mimic a range of acute abdominal pathologies, requiring increased suspicion,
timely diagnostic evaluation, and management. Rare bleeding such as RSH may be encountered
with DAPT. Emergency medicine physicians and cardiologists should consider RSH in
patients presenting with abdominal pain and using DAPT with ticagrelor.
