Atypical presentation of catastophric spontaneous mesenteric bleeding

Abstract

Spontaneous mesenteric bleeding is an exceptionally rare clinical condition and potentially lethal especially among elderly patients who are taking oral anticoagulant. We present a case of a 79-year-old woman who presented to the emergency department with atypical chest pain which was radiating to the back. She developed profound hypotension with a sudden drop of haemoglobin. Contrast-enhanced CT of the aorta showed active mesenteric bleeding with mesenteric haematoma. The early diagnosis relies solely on a high index of suspicion of occult bleeding in patients with unexplained hypotension with a sudden drop of haemoglobin. Troponin can be falsely positive in mesenteric bleeding. Close monitoring to detect any sign of deterioration and early imaging in diagnosing intra-abdominal bleeding can help to avoid delay in treatment which is essential to prevent mortality and morbidity.

Background

Mesenteric bleeding is a rare clinical condition which is usually caused by abdominal trauma.¹ Non-traumatic spontaneous bleeding can be seen in patients with variceal rupture from hepatic cirrhosis,^{2 3} visceral artery aneurysm rupture,⁴ pseudoaneurysm from complicating acute pancreatitis,⁵ Crohn’s disease, incarcerated inguinal hernia, connective tissue diseases such as Ehlers-Danlos syndrome, and patients on anticoagulation therapy such as warfarin,⁶ rivaroxaban.⁷ Superior mesenteric artery is the most common bleeding vessel, with lesser extent from inferior mesenteric artery, and unknown origin. It usually presents with non-specific symptoms such as abdominal pain, vomiting, abdominal mass, diarrhoea and melaena. Increasing bleeding can lead to hypotension. Mesenteric bleeding is diagnosed by multidetector CT angiogram which allows the identification of active extravasation of contrast material to locate the source of haemorrhage.⁸ It has high sensitivity and accuracy for detecting active bleeding.⁹ In cases where CT scan findings are indeterminate, MRI is the next choice of investigation as it is a sensitive investigation and assists in determining vascular or biliary tree involvement. In cases of haemodynamically stable mesenteric haematoma, it can be conservatively managed. Surgical intervention in the form of laprotomy and exploration or radiological intervention have been recommended for unstable and active bleeding patients. Here, we present an atypical case of spontaneous mesenteric bleeding in an elderly patient who was taking apixaban, a direct inhibitor of Factor Xa.

Case presentation

A 79-year-old woman presented with left sided sharp chest pain, which was radiating to the back and left shoulder. There was no history of trauma, abdominal pain, syncope, difficulty in breathing, palpitation, cough, vomiting, diarrhoea, melaena or haematamesis. She had background history of hiatal hernia, scoliosis, lymphoedema, bronchial asthma, hypercholesterolaemia, atrial fibrillation and previous two episodes of pulmonary embolism. She was taking apixaban 2.5 mg two times a day, clopidogrel 75 mg one time a day, fenofibrate 200 mg one time a day, gabapentin 300 mg three times a day, oxybutynin 5 mg one time a day, salbutamol aerosal inhaler 100 µg four times a day, beclometasone 100 µg aerosol inhaler two times a day. She had presented with similar chest pain 3 weeks ago prior to this presentation and had CT coronary angiogram done which was unremarkable. On examination, she was confused, breathless and had equal air entry on both chest without wheeze or rhonchi. She had cold peripheries and blood pressure of 66/22 mm Hg, heart rate of 112/min, saturation of 96% under room air. Abdomen was soft, not distended and had generalised minimal tenderness.

Investigations

Initial venous blood gas showed pH 7.257 (7.35–7.45), bicarbonate 20 (22–26 mmol/L), base excess −6.7, lactate 3.7 (<2 mmol/L), which were consistent with metabolic acidosis and lactic acidosis. Blood investigation showed haemoglobin of 9.2 (11.5–16.0 g/dL), white cell count 8 (4–11×10⁹/L), platelet 307 (150–400×10⁹/L), C reactive protein 23 (<10 mg/L), sodium 137 (135–145 mmol/L), potassium 3.5 (3.5–5.3 mmol/L), urea 4.8 (2.5–6.7 mmol/L), creatinine 61 (70–100 μmol/L), troponin 313 (<13 ng/L), Alanine aminotransferase (ALT) 41 (10–60 U/L), prothrombin time 15.4 (10–14 s), and International Normalized Ratio (INR) 1.38 (1 s). Haemoglobin dropped to 7.1 g/dL when repeated within 1 hour. ECG showed atrial fibrillation in fast ventricular rate. CT aorta angiogram revealed a focus of active contrast extravasation admist ill defined areas of mixed density abdominal collection in the central mesentery (figure 1). This represented active mesenteric bleeding with surrounding intraperitoneal haematoma. Arterial phase images suspected bleeding was arising from mesenteric vessel. Large left sided diaphragmatic hernia containing abdominal viscera was also noted. Mixed density attenuation was seen within the sac in keeping with haematoma extension from mesenteric bleed. There was satisfactory opacification of the coeliac artery, superior mesenteric artery, renal arteries and inferior mesenteric artery. Thoracic aorta was atherosclerotic but there was no evidence of aortic dissection. Factor Xa activity and fibrinogen levels were not measured due to unavailability.

Figure 1.

Axial contrast-enhanced CT of abdomen and pelvis showed linear extravasation of contrast material as well as intrabdominal hyperattenuating material.

Differential diagnoses

Chest pain in the context of underlying cardiovascular risk factors warrants an ECG and troponin level to rule out any myocardial infarction, which is way more common. ECG did not show any dynamic changes suggesting acute coronary syndromes in this case. With history of two episodes of pulmonary embolism, this patient’s chest pain was likely to be another episode of pulmonary embolism as it is prone to be recurrent. At this age with multiple comorbidities that pose her a high risk of cardiovascular diseases, abdominal aortic aneurysm is another differential to be considered in this case. This differential was ruled out by CT angiogram. At the same time, aortic dissection should be considered as well in this presentation in a patient with advanced age and multiple underlying cardiovascular risks.

Treatment

Multidisciplinary team was involved in management of the patient. Beriplex, vitamin K and two packed red cells were initially administered after consultation with haematologist oncall. Intensive care unit was involved and an inotrope metaraminol was given in order to maintain mean arterial pressure above 65 mm Hg. Surgical team contacted a vascular surgeon and an interventional radiologist from a tertiary hospital and patient was blue lighted for transfer.

Outcome and follow-up

The patient underwent coeliac and superior mesenteric angiogram which demonstrated a small pseudoaneurysm from an aberrant pancreatic branch of the common hepatic artery. Small collateral supply to this pancreatic branch from the superior mesenteric artery was also noted. Superselective catheterisation of the aberrant pancreatic branch was performed through the common hepatic artery. Glue embolisation (Glubran 2) of the back door, pseudoaneurysm sac of aberrant pancreatic branch of the common hepatic artery, front door and the small collateral supply from superior mesenteric artery were successfully performed. Repeated angiogram demonstrated complete exclusion of the pseudoaneurysm with no active contrast leak or contrast pooling. However, the patient underwent disseminated intravascular coagulation and passed away after 3 days of hospitalisation.

Discussion

Mesenteric bleeding or haematoma is a very rare condition with no specific or typical presentation. Through literature search, it can present as acute abdomen associated with vomiting and diarrhoea, upper or lower gastrointestinal bleeding, hypovolaemic shock or asymptomatic abdominal mass. Acute abdomen would necessitate clinical judgement based on history and investigations to rule out other common causes before considering mesenteric bleeding. Gastrointestinal bleeding, another common presentation in surgical abdomen, could be also caused by mesenteric haematoma which ruptures into intestine without any predisposing factor.¹⁰ Chronic mesenteric haematoma on the other hand can mimic tumour in asymptomatic patient presented with abdominal mass.^{11 12} Comparing with our case here, it is the first case in which patient presented with chest pain, emphasising the diagnostic difficulty of mesenteric bleeding as it has various diverse presentations which will put clinicians in dilemma. We postulate that the presence of underlying large abdominal hernia may lead to false chest pain rather than abdominal pain as presentation in the first instance. Furthermore, false-positive troponin can mislead a clinician to treat it as acute coronary syndrome in the context of advanced age and presence of significant cardiovascular risk factors. The current best investigation for mesenteric bleeding would be CT angiography, which showed active contrast extravasation and helps to locate the bleeding vessels. However, there are reports on diagnostic dilemma even with CT in cases where the bleeding is chronic and minimal, mimicking a tumour, especially in elderly group, and this would potentially render patient to unnecessary surgery if it cannot be ruled out from investigations.¹² Diagnosis of mesenteric bleeding still heavily depends on CT angiography until and timely diagnosis is life-saving as demonstrated by many reports that patient can deteriorate very fast and succumb to haemorrhagic shock. It is therefore must be considered in a case of abdominal apoplexy or idiopathic spontaneous intra-abdominal haemorrhage, which can happen even with normal coagulation profile and no evidence of pseudoaneurysm.^{13 14} To our knowledge, we are the second to report on the association of apixaban use with spontaneous mesenteric haematoma, with the first report also noted spontaneous visceral arterial pseudoaneurysms which caused mesenteric bleeding in their patient prescribed with apixaban for prosthetic heart valve.¹⁵ As commonly believed, warfarin is widely known as the culprit for bleeding tendency which includes mesenteric bleeding. Though having less risk of bleeding, similar drug to apixaban, rivaroxaban has also been reported as the cause of mesenteric bleeding in patient presented with abdominal pain, diarrhoea and melaena.¹⁶ Our case and these similar cases demonstrate the difficulty in diagnosing mesenteric haemorrhage in patients taking direct oral anticoagulants because they cannot be monitored biochemically like in warfarin, even though having lesser risk of bleeding. Nonetheless, mesenteric bleeding was also reported in case even without the use of anticoagulant.¹⁷

Learning points.

• Mesenteric bleeding can present with atypical chest pain with falsely raised troponin level, if concurrently happen in a case of diaphragmatic hernia, which is common among elderly patients as well.

• Sudden drop of haemoglobin with unexplained hypotension and raised lactate without any obvious external bleeding warrants active investigation for internal bleeding in a patient, especially those taking any anticoagulants, even with direct oral anticoagulants.

• High index of suspicion of mesenteric active bleeding is necessary for early diagnosis with urgent angiography and timely management with immediate resuscitation and prompt radioglogical intervention to control bleeding.

• Prognosis is poor in elderly patients who presents late and rapid deterioration can happen.

Ethics statements

Patient consent for publication

Next of kin consent obtained.