Bleeding Lateral Oblique Hematoma in a Coagulopathic Female with Hemophilia B

Valerie Fiore, DO¹, Jovia Williams², Marc Knezevic-Maragh, MPH², Caleb Bonsu², Oluwatito Roberts², Delcasse Joseph, MD^1
1Department of Surgery, Episcopal Health Services, Far Rockaway, New York
²Department of Medicine, Ross University School of Medicine, Bridgetown, Barbados

Introduction: 

Lateral oblique abdominal wall hematoma is exceedingly rare but tends to mimic other abdominal pathologies due to its nonspecific presentation, including localized pain, swelling, and ecchymosis.¹ The external and internal oblique muscles are supplied by segmental branches of the lower intercostal, subcostal, and lumbar arteries, which can be susceptible to rupture in the setting of coagulopathy, trauma, or increased intra-abdominal pressure.² Once the vascular structures are compromised, a lateral oblique hematoma tends to rapidly expand and compress adjacent structures, leading to symptoms that can mimic pathologies like abdominal hernia, pancreatitis, and bowel obstruction. More severe incidences are treated with IR angioembolization or operative control.³ We report the case of a 40-year-old female with known Hemophilia B who presented with hematemesis, hematochezia, fever, and persistent cough in the setting of Influenza A infection.

Case Presentation: 

A 40-year-old female with history of factor IX deficiency, alcoholic cirrhosis, anemia requiring transfusions, and previous episodes of gastrointestinal bleeding presented with 3 days of hematemesis, bleeding per rectum, fever, myalgias, and persistent cough. She was febrile, hypotensive and tachycardic. On examination, she had LUQ tenderness and distension, and blood on DRE.  She had a hemoglobin of 5g/d, hematocrit of 15.7%, leukocytosis of 20.8 10^3/uL. PT, INR, and PTT were 23.9 sec, 2.08 units, and 41.6 sec.  She had hypokalemia of 2.6 mmol/L, hypomagnesemia of 0.6 mg/dL, and hypocalcemia at 7.1 mg/dL. She was positive for Influenza A. She was s/p 2u pRBC, raising her Hgb to 7. Empiric treatment for gastrointestinal bleeding was initiated with IV pantoprazole and octreotide. CT and a tagged RBC scan were performed. Within 24 hours, the patient developed diffuse abdominal tenderness and increased swelling of the LUQ abdominal wall. An emergent transfer was arranged to a care center with interventional radiology capabilities for angioembolization.