Pain in the hip: Spontaneous retroperitoneal hemorrhage in an elderly patient on apixaban.

As many as 5% of patients using oral anticoagulants suffer from a major bleeding event annually. Spontaneous retroperitoneal hemorrhage is a rare but serious complication, with a mortality rate as high as 20%. Oral anticoagulants were responsible for 2.83 million office visits per quarter in 2014 and use is increasing, therefore, rapid recognition of life threatening complications is critical. We present a case of an 86-year-old female taking apixaban for atrial fibrillation who presented with right hip pain upon standing. Laboratory tests revealed leukocytosis and anemia. A CT scan of the right hip revealed a moderately sized retroperitoneal hematoma. She was transferred to the intensive care unit, treated with supportive care, and was discharged two days later without any invasive intervention needed. Due to vague presentations, spontaneous retroperitoneal hemorrhages can be misdiagnosed as a number of abdominal or pelvic processes. While our patient presented with hip pain, other presentations include abdominal masses, back pain, or hypotension. Some patients may progress to hemodynamic instability, femoral neuropathy, or abdominal compartment syndrome requiring rapid intervention to prevent further morbidity. In patients with vague abdominal or pelvic complaints who have risk factors such as advanced age and the use of anticoagulation therapy, spontaneous retroperitoneal hemorrhage should be considered to allow for early diagnosis before severe complications arise.