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Hong Kong Journal of Emergency Medicine

Iliopsoas haematoma: an uncommon differential diagnosis for groin pain

GPH Choa and CS Lim

Bleeding complications should be considered in the differential diagnosis of any patient on warfarin therapy. A 66-year-old man presenting with right groin pain due to a spontaneous iliopsoas hematoma is reported. Computed tomography of the abdomen and pelvis at the emergency department confirmed the diagnosis. Fresh frozen plasma was given to correct the clotting derangement. The patient was managed conservatively. He was subsequently discharged well without complication. Iliopsoas haematoma or spontaneous retroperitoneal haemorrhage is an uncommon complication that needs to be considered in the differential diagnosis of a patient on warfarin therapy with abdominal, flank or groin pain. (Hong Kong 2011;18:173-176)

warfarin 66 warfarin

Keywords: Coagulation disorder haemorrhage, retroperitoneal, warfarin

Case report

A 66-year-old man presented to the emergency room complaining of right groin pain and right lower back pain for three days. The pain started shortly after playing a game of golf three days earlier. The groin and back pain was getting progressively worse and was exacerbated by ambulation and movement of the right hip. The patient could not recall any specific incident of back injury or trauma and he did not have a history of back pain. There was no sciatica or neurological

complaint involving the lower limbs. No bladder or bowel symptoms were reported. There was no abdominal pain. The patient also denied a history of urinary calculus. The patient had a history of sick sinus syndrome treated with pacemaker insertion. He was on warfarin for atrial fibrillation. He also had acute myeloid leukaemia four years ago. He had been in remission after chemotherapy. The patient was comfortable at rest. Vital signs were normal. The abdomen was soft and non-tender. No pulsatile mass was detected and both femoral pulses were equal. The kidneys were not ballotable and there was no loin tenderness. There was no hernia and the scrotal contents were normal. The anal tone was good and there was no saddle anaesthesia. The neurological examination of the lower limbs was normal.

Correspondence to: Choa Peng Hui, Gary, MBBS, MMed, MRCS(Edin) Singapore General Hospital, Department of Emergency Medicine, 1 Outram Road, Singapore 169608 Email: [email protected] Lim Chin Siah, MBBS, MMed, MCEM


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The patient was able to bear weight and ambulate with an antalgic gait. Forward flexion of the lumbar spine was normal but there was back pain on extension. Straight leg raising was full but the patient did complain of pain when the limb was being lowered. The range of movement of the right hip was full but again there was pain on extension of the right hip. Bedside urine dipstix analysis did not show any red blood cells or leukocytes. Ultrasonography of the abdomen was done. The abdominal aorta was not enlarged and there was no free fluid in the abdomen. The renal outlines were normal and there was no hydronephrosis. X-ray examination of the lumbar spine and pelvis revealed mild degenerative changes in both hip joints and lumbar spine and that of the kidney, ureter and bladder did not show any radioopaque calculus. However the right psoas shadow was obscured (Figure 1). His international normalised ratio (INR) was 2.6 one month ago. There was no recent adjustment to the

warfarin dosage and the patient claimed to have good compliance to his medications. However the INR in the emergency room (ER) was markedly elevated to 8.09. The full blood count also revealed a drop in haemoglobin from 13.1 g/dl to 12 g/dl over the past one month. Systemic enquiry did not reveal any source of bleeding that explained the drop in haemoglobin. A non-contrast computed tomography of the abdomen and pelvis was done at the ER. A 7.4 x 3.6 cm retroperitoneal haematoma in the right posterior pararenal space was found (Figure 2). There was also a right iliopsoas haematoma extending inferiorly to the thigh (Figure 3).

Figure 2. CT abdomen image shows a right posterior para-renal collection (arrow) consistent with retroperitoneal haemorrhage.

Figure 3. CT abdomen image shows an isodense swelling of the Figure 1. X-ray showing an ill-defined right psoas shadow (the left psoas shadow is well seen and indicated with arrows). right iliacus (big arrow) and psoas muscle (small arrow) consistent with a haematoma.

Choa et al./Iliopsoas haematoma


The patient was given fresh frozen plasma to correct his deranged coagulation profile and warfarin was discontinued. The retroperitoneal haematoma was treated conservatively. The patient was discharged 3 days later with a stable haemoglobin level and an INR of 3.5. The groin pain had resolved. Computed tomography was not repeated prior to discharge. Further inquiry showed that the patient had been taking off-the-counter anti-oxidant supplements for one month before presentation. The patient was reminded on the risks of over-anticoagulation and was advised against taking medications or supplements without consulting a physician.

rectus sheath haematomas and retroperitoneal haematomas. It has been reported that 1-7% of patients taking anticoagulants will suffer a bleeding complication each year.1 Iliopsoas haematomas uncommonly occur secondary to trauma due to the deep seated location of the muscles. Spontaneous iliopsoas haematomas are relatively more common and usually occur in patients with coagulopathy either due to haemophilia or anticoagulant therapy from warfarin or enoxaprin. 2 Bilateral iliopsoas haematomas are also described in literature. 3 Liver cirrhosis as a cause of spontaneous iliopsoas haematoma has also been reported. 4 There was one case report of a haematoma of the iliopsoas muscle from thrombocytopenia due to a third generation cephalosporin. 5 Muscular sprain from exertion, as in our patient, is an identified cause. However, there was a case report on a spontaneous iliopsoas haematoma in a patient who was neither on anticoagulant therapy nor suffering from a coagulopathy.6 Iliopsoas haematomas typically present with groin or thigh pain. Abdominal or flank pain may be present when there is retroperitoneal extension.7 Ecchymoses in the peri-umbilical area (Cullen's sign) or in the flanks (Grey-Turner's sign) may occur. 8 Large retroperitoneal bleeding may cause hypovolaemic shock. Compressive femoral neuropathy may occur in cases where the haematoma in the iliacus or psoas muscle is large enough to compress the femoral nerve as it passes through these muscles. 9,10 This usually presents as acute unilateral lower limb sensory numbness or paraesthesia. Muscle weakness may be present in chronic or more severe cases. Typically the hip is flexed in the involved side and pain is elicited on passive extension as the iliopsoas muscle is stretched. Compression of the ureter may cause hydronephrosis and acute renal failure may occur if the compression is bilateral. Compression of the inferior vena cava has also been reported to cause deep vein thrombosis.11 Ultrasonography has been used to diagnose iliopsoas haematomas but its sensitivity and specificity are user-


Patients often present with undifferentiated symptoms to the emergency department. Thorough history taking, careful clinical examination and consideration of relevant differential diagnoses are important. Although common diagnoses occur commonly, unusual but potentially life threatening causes must also be considered and excluded. This case illustrates an uncommon cause of a common complaint. For this patient who presented with right groin pain, differential diagnoses initially considered included ureteric colic, hernia, lumbar spondylosis with sciatica, abdominal aortic aneurysm and aortic dissection. Each was however in turn excluded through a combination of physical examination and bedside, radiological and laboratory investigations. In our patient, a grossly deranged INR and a drop in haemoglobin without overt bleeding prompted the request for a computed tomography of the abdomen to rule out retroperitoneal bleeding as a cause of his groin pain. Warfarin produces its anticoagulation effects by interfering with the vitamin K dependent carboxylation of prothrombin. It is used in various conditions such as atrial fibrillation, post mechanical valve replacement, and treatment and prevention of thromboembolic events. Bleeding complications associated with warfarin use include gastrointestinal and intracranial bleeds,


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dependent and it is also technically difficult due to the deep seated location of the muscle and obscuration by the ilium. Magnetic resonance imaging is the investigation of choice. Computed tomography is more readily accessible and is adequate for diagnosis of intramuscular and retroperitoneal haematomas. Treatment of spontaneous retroperitoneal haematoma is usually conservative as in our case. The deranged clotting profile may be corrected by fresh frozen plasma or vitamin K. Supportive measures with blood transfusion may be necessary. The INR, haemoglobin level and clinical symptoms should be monitored. Surgical decompression may be indicated in compressive femoral neuropathy.12 Warfarin is well known to interact with many medications which interfere with its metabolism and increase the risk of over-anticoagulation. Medical literature is also replete with case reports of various substances that may interact with warfarin. Physicians should be alert to the potential interactions with polypharmacy in patients on warfarin therapy. It may also be dangerous when patients take off-the-counter medications or health supplements. A thorough review of the patient's drug history and exclusion of self medication is thus important. Patients on warfarin should be reminded of this potential complication. Spontaneous retroperitoneal haematoma in patients who are on warfarin therapy is uncommon and has been described in literature. This case serves as a timely reminder that atypical presentations and uncommon causes must be considered in any patient on warfarin therapy. In particular, abdominal, flank, groin or thigh pain should trigger suspicion of an iliopsoas haematoma and retroperitoneal bleeding.


1. 2. Beyth RJ. Management of haemorrhagic complications associated with oral anticoagulant treatment. Expert Opin Drug Saf 2002;1(2):129-36. Dauty M, Sigaud M, Trossaert M, Fressinaud E, Letenneur J, Dubois C. Iliopsoas hematoma in patients with hemophilia: a single-center study. Joint Bone Spine 2007;74(2):179-83. Marquardt G, Barduzal Angles S, Leheta F, Seifert V. Spontaneous hematoma of the iliac psoas muscle: a case report and review of literature. Arch Orthop Trauma Surg 2002;122(2):109-11. Sugiyama C, Akai A, Yamakita N, Ikeda T, Yasuda K. Muscle hematoma: a critically important complication of alcoholic liver cirrhosis. World J Gastroenterol 2009; 15(35):4457-60. Onodera M, Fujino Y, Inoue Y, Kikuchi S, Endo S. Hematoma of the iliopsoas muscle due to thrombocytopenia resulting from the administration of a third generation cephalosporin. Ann Hematol 2010; 89(8):825-6. Wada Y, Yanagihara C, Nishimura Y. Bilateral iliopsoas hematomas complicating anticoagulant therapy. Intern Med 2005;44(6) 641-3. Kwon OY, Lee KR, Kim SW. Spontaneous iliopsoas muscle haematoma. Emerg Med J 2009;26(12):863. Morgan RJ, Bristol JB. Unusual findings in a patient taking warfarin. Postgrad Med J 1999;75(883):299-300. Jamjoom ZA, al-Bakry A, al-Momen A, Malabary T, Tahan AR, Yacub B. Bilateral femoral nerve compression by iliacus hematomas complicating anticoagulant therapy. Surg Today 1993;23(6):535-40. Ong HS. Compressive femoral neuropathy: a rare complication of anticoagulation. Singapore Med J 2007; 48(3):e94-5. Phillips S, Barr A, Wilson E, Rockall TA, Stebbing JF. Two cases of retroperitoneal haematoma caused by interaction between antibiotics and warfarin. Emerg Med J 2006;23(1):e8. Nakao A, Sakagami K, Mitsuoka S, Uda M, Tanaka N. Retroperitoneal hematoma associated femoral neuropathy: a complication under antiplatelet therapy. Acta Med Okayama 2001;55(6):363-6.




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