Article, Emergency Medicine

Spontaneus splenic rupture in a patient treated with rivaroxaban

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Splenic rupture in a patient “>Case Report

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American Journal of Emergency Medicine

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American Journal of Emergency Medicine 32 (2014) 950.e3

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Spontaneus splenic rupture in a patient treated with rivaroxaban

Abstract

Rivaroxaban is a direct competitive reversible and specific inhibitor of factor X that has gained increasing popularity for Stroke prevention in nonvalvular atrial fibrillation. We report the case of a 67-year-old man taking rivaroxaban 15 mg once daily for atrial fibrillation, who presented to the emergency department with acute abdominal pain. He was diagnosed of spontaneus splenic rupture with hemorrhagic shock. Despite treatment with Packed red blood cells, fresh frozen plasma, and prothrombin complex concentrates, the patient’s hemorrhagic shock persisted during 12 hours until splenec- tomy. Two days later, the patient developed Multiorgan dysfunction due to colic ischemia requiring a colectomy.

We describe a rare case of spontaneus splenic rupture that demonstrates the potential for serious bleeding from rivaroxaban toxicity.

rivaroxaban [4,5]. In the present case, the association between amlodipin (CYP3A4 inhibitor) and telmisartan/hydrochlorothiazide probably increased the rate of rivaroxaban causing a severe spleen bleeding without traumatic context [4,5].

When facing a severe hemorrhage in a critical organ, it is proposed to reduce the effect of anticoagulant therapy using procoagulant drugs (activated prothrombin concentrates, fresh frozen plasma, and recombinant activated factor VII) even if it lacks efficacy and safety [6,7]. However, in our case, the infusion of fresh frozen plasma and prothrombin complex concentrates did not show any efficiency. To this date, there is no available antidote to cope specifically with rivaroxaban’s side effects.

Finally, we presented the first case of a Nontraumatic splenic rupture with hemorrhagic shock due to rivaroxaban. With an effective antidote, the severe bleeding management of a patient receiving rivaroxaban could be improved.

In France, the most common agents used for prevention of Thromboembolic events, such as stroke and pulmonary embolism, were the vitamin K antagonists.

Rivaroxaban, a new oral anticoagulant, is more and more used for prevention of thromboembolic events since 2009.

We report the case of a 67-year-old man who arrived to the emergency department with an acute abdominal pain and dizziness. He was taking rivaroxaban 15 mg once daily for nonvalvular atrial fibrillation for 2 months. Besides, he was taking betaxolol, rosuvas- tatin, telmisartan/ hydrochlorothiazide, flecainide, and amlodipin.

Physical examination revealed that the pain was located on the left side. His skin was clammy. Vital signs were as follow: pulse of 61 beats per minute, blood pressure of 66/47 mm Hg, pulse oxygen saturation of 97% on breathing ambient air, respiration rate of 19 per minute, Glasgow Coma Scale at 15, and hemoglobin level at 10.3 g/dL. The patient was diagnosed with spontaneus splenic rupture by computed tomography. Our patient was administered prothrombin complex concentrates (1750 IU), an infusion of fluid resuscitation (colloids 500 mL and crystalloids 1000 mL) and norepinephrine, 4 packed red blood cells, and 4 fresh frozen plasma. In spite of this treatment, the patient’s hemorrhagic shock persisted during 12 hours until splenectomy. Two days later, the patient developed multiorgan dysfunction due to colic ischemia. Outcome was favorable after a colectomy.

New oral anticoagulants are known to be risk factors for gastrointestinal bleeding [1-3]. Comedication with antiplatelet ther- apy, strong inhibitor of both P-glycoprotein and CYP3A4 and drugs decreasing renal function, increases the risk of bleeding due to

Jonathan Gonzva, MD Roland Patricelli, MD David Lignac, MD

Department of Emergency Medicine Hospital, Nogent Le Rotrou, France

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.01.049

References

  1. Dentali F, Riva N, Crowther M, Turpie AG, Lip GY, Ageno W. Efficacy and safety of the novel oral anticoagulants in atrial fibrillation: a systematic review and meta- analysis of the literature. Circulation 2012;126(20):2381-91.
  2. Braun G, Messmann H. Gastrointestinal bleeding in cardiological patients. Med Klin Intensivmed Notfmed 2013;108(8):628-33.
  3. Holster IL, Valkhoff VE, Kuipers EJ, Tjwa ETTL. new oral anticoagulants increase the risk of gastrointestinal bleeding–a systematic review and meta-analysis. Ned Tijdschr Geneeskd 2013;157(44):A6500.
  4. Hellwig T, Gulseth M. Pharmacokinetic and pharmacodynamic Drug interactions with new oral anticoagulants: what do they mean for patients with atrial fibrillation? Ann Pharmacother 2013;47(11):1478-87.
  5. Pfeilschifter W, Luger S, Brunkhorst R, Lindhoff-Last E, Foerch C. The gap between trial data and clinical practice–an analysis of case reports on bleeding complica- tions occurring under dabigatran and rivaroxaban anticoagulation. Cerebrovasc Dis 2013;36(2):115-9.
  6. Pernod G, Albaladejo P, Godier A, Samama CM, Susen S, Gruel Y, et al. Management of major Bleeding complications and emergency surgery in patients on Long-term treatment with direct oral anticoagulants, thrombin or factor-Xa inhibitors. Proposals of the Working Group on Perioperative Haemostasis (GIHP)–March 2013. Ann Fr Anesth Reanim 2013;32(10):691-700.
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