An unusual cause of abdominal pain due to a psoas haematoma post stroke in a patient on anticoagulation

Edukulla, M., Abbasi, A and Marigold, R. (2024) An unusual cause of abdominal pain due to a psoas haematoma post stroke in a patient on anticoagulation. International Journal of Stroke, 19 (3 Suppl.). (doi:10.1177/17474930241300284).

Abstract

Introduction: psoas muscle haematoma is rare, and can be spontaneous, due to trauma, anticoagulation or antiplatelet therapy or haematological disorders. We present the case of a patient with an ischaemic stroke and new atrial fibrillation, who was anticoagulated, fell and had a right sided hip fracture which was repaired, but then developed left sided abdominal | hip pain a few weeks later.

Method: an 81-year-old male was admitted for a urinary tract infection and progressive right leg weakness. An MRI revealed acute ischaemia of the left corona radiata. He later suffered an unwitnessed fall, resulting in a right inter trochanteric femoral fracture, which was treated with internal fixation. Two weeks later his apxiaban had been restarted and was thought to have further urosepsis, but his white cell count and CRP did not improve despite intravenous antibiotics and there was a fall in haemoglobin.

Results: a CT abdomen and pelvis was done to look for an intraabdominal collection. Somewhat surpisingly, an iliopsoas abnormality with multiple small sub-2cm rim-enhancing foci of fluid, thought to be an organised haematoma. Apixaban was stopped, he was transfused and treated with intravenous antibiotics and repeat imaging 2 weeks later revealed haematoma resorption. Antiphospholipid antibodies positive, anticardiolipin negative throught to be due to DOAC treatment.

Conclusions: psoas haematoma is an unusual form of intra-abdominal haemorrhage, which in this case followed trauma and anticoagulation. Presentation is commonly with abdominal pain and bruising, but atypical symptoms can occur as in this case. Abdominopelvic imaging with CT|MRI can aid diagnosis.

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