Symptomatic reversible duodenal compression due to iatrogenic retroperitoneal hematoma

Spontaneous retroperitoneal hematoma with duodenal obstruction with diagnostic use of endoscopic ultrasound: A case series and literature review

Spontaneous retroperitoneal hematoma is rare and can cause duodenal obstruction. We report four cases of spontaneous retroperitoneal hematoma with duodenal obstruction, wherein endoscopic ultrasound was useful for diagnosis. The patients complained of vomiting with stable vital signs. Computed tomography, esophagogastroduodenoscopy, and endoscopic ultrasound findings were similar in all cases. Contrast-enhanced computed tomography revealed a low-density mass around the 2nd to 3rd part of the duodenum. Esophagogastroduodenoscopy showed an edematous, reddish, but non-neoplastic duodenal mucosa with stenosis of the lumen. Endoscopic ultrasound revealed a low-echoic mass around the duodenum and high-echoic floating matter suggesting debris and anechoic areas that indicated a liquid component. These findings suggested hematomas or abscesses. Although pseudoaneurysm of the pancreaticoduodenal artery was suspected in Case 3, we chose conservative treatment because the aneurysm was small. In Case 4, median arcuate ligament syndrome was suspected on angiography. No aneurysms or arteriovenous malformations were found; thus, endovascular embolization was not performed. The patients were treated conservatively and discharged within 3-5 weeks. English literature queries on spontaneous retroperitoneal hematoma with duodenal obstruction in MEDLINE revealed 21 cases in 18 studies. The clinical features of these patients and the present four cases have been discussed.

Sertraline-induced periorbital purpura: a case report

OBJECTIVE

The incidence of mild to severe levels of spontaneous bleeding due to the usage of selective serotonin reuptake inhibitors (SSRIs) is relatively low. Although the exact mechanism is not known, it is thought that inhibition of the serotonin transporter together with a decrease in platelet serotonin could be responsible for the bleeding. Therefore, the use of SSRIs in conjunction with anti-aggregants may predispose to or exacerbate the risk of bleeding. In this case report, we describe a 44-year-old female patient with a diagnosis of anxiety disorder who spontaneously developed periorbital purpura during treatment with sertraline.

CONCLUSION

Abnormal bleeding after treatment with an SSRI should be kept in mind, and alternative non-SSRI drugs of choice in such cases would be more appropriate. More extensive and comprehensive studies focusing on hemostasis and bleeding disorders are needed for SSRIs such as sertraline.

Retroperitoneal haematoma causing gastric outflow obstruction following endovascular repair of a ruptured abdominal aortic aneurysm

A 74-year-old man presented with back pain and collapse. A ruptured infrarenal abdominal aortic aneurysm was successfully managed by endovascular aneurysm repair. Postoperatively, he developed gastric outlet obstruction owing to duodenal compression from the unevacuated retroperitoneal haematoma. In the absence of abdominal compartment syndrome, conservative management with gastric decompression and parenteral nutrition led to a full recovery.

Bilateral spontaneous retroperitoneal bleeding in a patient on nimesulide: a case report

Introduction

Spontaneous retroperitoneal bleeding is a rare but potentially life-threatening event of varied etiology. Herein we report a case of bilateral non-traumatic retroperitoneal hemorrhage.

Case presentation

A 50-year-old Greek man, who was on a non-steroidal anti-inflammatory agent (nimesulide) for ankylosing spondylitis, presented with a right retroperitoneal hematoma combined with contralateral subcapsular renal hematoma. Bleeding on his right side was successfully controlled by arterial embolization with coils, whereas the left renal hematoma was treated conservatively. His recovery period was uneventful.

Conclusion

This is the first reported case of bilateral retroperitoneal bleeding in a patient receiving nimesulide for ankylosing spondylitis. The application of minimally invasive techniques resulted in the desired positive outcome with preservation of both renal units.

Selective serotonin reuptake inhibitors and risk of upper GI bleeding: confusion or confounding?

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) represent a relatively new class of antidepressants. Several studies have reported bleeding disorders associated with the use of SSRIs, which are considered the result of a decrease in platelet serotonin leading to a defect in platelet aggregation. To what extent the use of SSRIs increases the risk of gastrointestinal bleeding is unclear.

METHODS

A comprehensive literature search for studies addressing SSRI use and upper gastrointestinal tract bleeding (UGIB) was conducted using Medline, EMBASE, and Cochrane databases with a recursive manual reference search up to May 2005. Any observational and interventional studies were systematically reviewed, and critical appraisal was conducted on available studies.

RESULTS

Published clinical evidence on the relationship between SSRI use and gastrointestinal bleeding is limited to observational studies without any clinical trials. Three cohort studies and one case-control study met inclusion criteria. These studies combined different affinity SSRIs in the class and had differing control groups with conflicting conclusions. Both a cohort study and a case-control study investigating the concurrent use of nonsteroidal anti-inflammatory drugs (NSAIDs) or low-dose aspirin found that combined use with an SSRI increased the risk of UGIB.

CONCLUSIONS

Only a few epidemiology studies have investigated the association between SSRIs and UGIB. They provide weak evidence to support the hypothesis of a link between SSRIs and UGIB at a population level. Available evidence shows that concurrent use of NSAIDs or aspirin with SSRIs greatly increases the risk of UGIB. The preventive strategy should be considered in those SSRI users at high risk, especially the elderly or those with a history of UGIB and taking nonselective NSAIDs or aspirin.

Selective serotonin reuptake inhibitors and increased bleeding risk: are we missing something?

PURPOSE

Selective serotonin reuptake inhibitors (SSRIs) are first line agents to treat clinical depression. Although these medications exhibit a favorable safety profile, there are multiple case reports, registries, and uncontrolled studies suggesting that use of SSRIs might be associated in the increased risk of bleeding events. There is also emerging evidence that these side effects of SSRIs are due to blockade of serotonin reuptake in platelets and subsequent platelet dysfunction.

METHODS

The analysis of evidence linking SSRIs with bleeding episodes to define the prevalence, specific clinical characteristics, and estimated risk when SSRIs are used in combination with antiplatelet agents or/and anticoagulants.

RESULTS

There are over 120 MEDLINE-cited peer-reviewed research papers and more than 50000 Web pages devoted to SSRI-related bleeding events.

CONCLUSION

Independently of the brand, use of SSRIs is indeed associated with increased bleeding risk. Although such complications are rare, their frequency is growing, and physicians should be aware of SSRI-induced hemorrhages, especially in patients with hereditary platelet defects, and those treated with antiplatelet agents. Prospective studies are urgently needed to determine whether SSRIs will yield additional bleeding risks when used long term concomitantly with aspirin or clopidogrel.