Spontaneous Perigastric Hematoma and Hemoperitoneum Associated With Rivaroxaban Therapy: A Case Report and Review of the Literature.

Spontaneous hemoperitoneum is a rare but potentially life-threatening complication of direct oral anticoagulant (DOAC) therapy. We report the case of a 59-year-old man receiving long-term rivaroxaban for atrial flutter, previously treated with tricuspid isthmus ablation, who was admitted for atypical chest pain and subsequently developed acute abdominal pain during observation. Contrast-enhanced computed tomography (CT) revealed spontaneous intra-abdominal hemorrhage presenting as a perigastric hematoma with hemoperitoneum, with the perigastric component measuring 96 mm × 58 mm, without active contrast extravasation or an underlying focal lesion. Throughout the admission, the patient remained hemodynamically stable, with no active contrast extravasation on CT and only a moderate decline in hemoglobin levels, from 14.8 g/dL at admission to a nadir of 12.3 g/dL, without requiring transfusion. He was managed with interruption of rivaroxaban and close clinical and biological monitoring alone, with full recovery and no invasive procedure required. A focused review of six comparable published cases of rivaroxaban-associated spontaneous intra-abdominal hemorrhage showed that most required invasive intervention for hemodynamic instability, underscoring the favorable outcome in this hemodynamically stable patient and supporting an individualized, severity-adapted approach to management. The case is notable for the combination of a sizeable perigastric hematoma, moderate hemoperitoneum, absence of active extravasation, hemodynamic stability, and successful non-invasive management. This combination appears to be rarely reported among previously published rivaroxaban-associated intra-abdominal hemorrhages, which predominantly required invasive intervention.