BMJ Case Reports 2018; doi:10.1136/bcr-2018-225136
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Spontaneous rectus sheath haematoma due to cough on apixaban

  1. Kulothungan Gunasekaran4
  1. 1Internal Medicine, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
  2. 2Internal Medicine, Sinai Grace Hospital, Detroit, Michigan, USA
  3. 3Pulmonary and Critical Care, Avera Health, Sioux Falls, South Dakota, USA
  4. 4Hospital Medicine, Henry Ford Health System, Detroit, Michigan, USA
  1. Correspondence to Dr Kulothungan Gunasekaran, stankuloth{at}
  • Accepted 6 April 2018
  • Published 11 April 2018


A 69-year-old woman on apixaban for 4 years due to her atrial fibrillation presented with severe left lower abdominal pain. She was discharged from the hospital 4 days prior after treatment for influenza and had finished a course of oseltamivir. She did not receive any heparin products and was continued on apixaban during that admission. A few hours before presentation, she reported coughing severely with sudden onset of excruciating abdominal pain. She denied trauma or injury to the abdomen. On exam, she was alert, normotensive and tachycardic, with significant left lower quadrant tenderness in the abdomen. Laboratory results were significant for decreased haemoglobin from 15.2 to 12.9 g/dL. CT of the abdomen showed acute left inferior rectus abdominis muscle haematoma (7.5 cm), along with stable and unchanged left adnexal cystic lesion (figure 1). Apixaban was discontinued, and the patient was closely monitored in the hospital …

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