Severe postoperative hemorrhage in a patient on dietary and herbal supplements

Post-operative haemorrhage secondary to cinnamon use. A case report

Introduction

Herbal medicine plays a significant role in modern medicine. The difficulty in integrating the two, lies in the unknown quantities of active ingredients in herbal remedies. This proved true in this clinical scenario. The quantity of coumarin, in the form of cinnamon ingested by this patient over ten months is unknown. The only quantifiable measure was the derangement in his extrinsic coagulation pathway.

Presentation of case

A 49-year-old male with a history of celiac disease presented with haematochezia secondary to a malignant adenocarcinoma of the transverse colon. The patient underwent a laparoscopic subtotal colectomy and on the second post-operative day, he was noted to have peritonitis and a positive Fox sign. Diagnostic laparoscopy confirmed intraabdominal bleeding. Over the next four days, the patient's haemoglobin plummeted from 17.4 g/dL to 8.0 g/dL. Investigations revealed an INR of 1.59, which led to further questioning into dietary practices. The patient admitted he had been taking Ceylon cinnamon one tablespoon daily for ten months in the period leading up to surgery.

Discussion

Coumarin is a chemical compound readily available in food items such as cinnamon. Coumarin possesses the ability to inhibit vitamin K epoxide reductase complex 1 which is responsible for the recycling of vitamin K. This impedes the gamma-carboxylation of coagulation factors II, VII, IX, X. Vitamin K antagonism can manifest as a prolonged INR and normal activated partial thromboplastin time.

Conclusion

Bleeding diathesis secondary to dietary coumarin is a rare but dangerous phenomenon that emphasizes the need for a thorough interrogation into a patient's dietary history.

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Cinnamon is a coumarin that can cause coagulopathy when used in excess.

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Dietary coumarin is a recognized cause of postoperative haemorrhage.

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Reactive haemorrhage can cause significant morbidity.

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Coagulopathy due to dietary coumarin can be rectified with fresh frozen plasma.

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A thorough dietary history is imperative in safe patient care.