Hemorrhagic Shock from Massive Retroperitoneal and Pelvic Hematoma After Stapled Hemorrhoidopexy

Abstract

Background: Massive retroperitoneal and pelvic hematoma leading to hemorrhagic shock following stapled hemorrhoidectomy is rare. To the best of our knowledge at the time of this publication, there are no reported cases of postoperative pelvic or retroperitoneal hematoma without intraluminal bleeding reported after stapled hemorrhoidopexy. We describe such a case in a patient with grade III internal hemorrhoid who was treated with colonoscopy and stapled hemorrhoidectomy. Case Summary: A 64-year-old female with a past medical history significant for deep vein thrombosis and pulmonary embolism for which she was anticoagulated with warfarin presented with hemorrhoids and rectal bleeding and associated iron deficiency anemia. The warfarin was held five days prior to the planned combined colonoscopy and hemorrhoidectomy procedure. While still recovering in the post-anaesthesia care unit (PACU) a few hours post-operatively, she was found to be hypotensive, tachycardic, and somnolent. A CT abdomen/pelvis was obtained, which identified a large collection of blood in the pelvis and retroperitoneum. She was taken back to the OR for an emergent exploratory laparotomy and flexible sigmoidoscopy. She was admitted to the ICU where she required placement on BiPAP for respiratory acidosis and resuscitation with a total of seven units of pRBCs and two units of FFP. She was clinically stable three days later. Conclusion: In a patient with a history of chronic anticoagulation, one should consider intraluminal, retroperitoneal, and pelvic bleeding if the patient is in hemorrhagic shock after stapled hemorrhoidectomy. Furthermore, one should not rule out the possibility of retroperitoneal or pelvic bleeding even if there is no evidence of intraluminal bleeding. Emergent laparotomy and sigmoidoscopy may be considered for unstable patients with unidentified external bleeding.