Apixaban-Associated Spontaneous Rectus Sheath Hematoma: A Geriatric Anticoagulation Dilemma in an 87-Year-Old Woman

Abstract

Spontaneous rectus sheath hematoma (RSH), a rare complication of anticoagulation therapy, can pose significant diagnostic and management challenges. We present the case of an 87-year-old woman with atrial fibrillation, hypertension, and chronic kidney disease (CKD) who developed spontaneous RSH while on apixaban. She presented with acute abdominal pain and a palpable mass, accompanied by anemia and coagulopathy. Non-contrast computed tomography (CT) confirmed a large rectus sheath hematoma. Conservative management, including discontinuation of apixaban, administration of tranexamic acid, and close monitoring, led to clinical improvement without requiring invasive intervention. This case underscores the importance of recognizing RSH in anticoagulated patients, particularly elderly individuals with renal impairment. Clinicians must maintain a high index of suspicion for atypical bleeding sites in patients on direct oral anticoagulants (DOACs) and consider conservative strategies when managing hemodynamically stable cases. The report highlights the need for individualized risk-benefit assessments when resuming anticoagulation and emphasizes patient education on bleeding risks.