Abstruse

We report the case of a 59-yr-old obese female who developed an abdominal wall haematoma during administration of prophylactic clexane. Compared with the non-obese, the subcutaneous tissue of the obese is considered dysfunctional and has a different vascular construction and extra-cellular matrix limerick. While the evolution of an intestinal wall haematoma is relatively uncommon, when they occur they tin have fatal consequences. The altered subcutaneous tissue environment in the obese attenuates the normal external pinch of an intestinal wall haematoma and every bit a result the obese are at greater chance of haemorrhage.

INTRODUCTION

Haematomas of the superficial intestinal wall occur infrequently in the infirmary setting. Though uncommon the well-described complications of an abdominal wall haematoma include uncontrolled haemorrhage requiring blood product transfusion and death [1]. A number of factors are known to predispose to the development of an abdominal wall haematoma. These include older historic period, female sex and the use of anti-platelet or anti-coagulant agents [2].

Obesity is an additional cistron that may complicate the formation of an abdominal wall haematoma. Compared with the non-obese, the sub-cutaneous tissue of the obese is considered dysfunctional and has a different vascular structure and extra-cellular matrix composition. The self tamponade effect that limits the extension of an abdominal wall haematoma may be deficient in the obese. Here we report the example of a 59-year-sometime obese female who adult an abdominal wall haematoma and haemodynamic instability during admission in our infirmary.

Instance REPORT

A 59-yr-old obese female was admitted to the hospital with fever on the background of poorly controlled Type 2 diabetes (Hba1c ix.five%). The patient's background included ischaemic heart disease, chronic kidney disease, peripheral vascular disease and a correct-side, below-knee amputation. On examination, the patient'due south weight was 125 kg, height 154 cm and body mass alphabetize was 53. A diabetic human foot ulcer was identified at the base of the left heel.

Two weeks later, the patient remained hospitalized for the management of an infected diabetic foot ulcer and awoke one morning with acute abdominal hurting and shortness of jiff. The patient was haemodynamically compromised with a pulse charge per unit of 120 and blood pressure ninety/lx lying. The haemoglobin fell overnight from 126 to 90 g/l and a few hours subsequently in that location was a further fall to 79 thou/l. The medical emergency squad were chosen. Platelet count was 242, international normalized ratio (INR) one.0, activated partial thromboplastin fourth dimension (APTT) 33 and anti-gene Xa level 0.41 in keeping with prophylactic clexane administration. A CT scan was performed, which demonstrated a big abdominal wall haematoma (see Fig.1).

Figure 1:

CT abdomen of a 59-year-old obese female with an abdominal wall haematoma.

CT abdomen of a 59-year-former obese female with an abdominal wall haematoma.

Figure 1:

CT abdomen of a 59-year-old obese female with an abdominal wall haematoma.

CT abdomen of a 59-year-old obese female with an abdominal wall haematoma.

Discussion

At that place are limited information on the relationship between weight or trunk mass index (BMI) and the evolution of an abdominal wall haematoma [3]. In the case series we reviewed, the weight or BMI of the patient is rarely mentioned. Nevertheless, where a photographic paradigm is published, the patient's weight and abdominal girth often appear excessive [four].

It has been recognized that women are more prone to haematoma formation owing to the relative lack of abdominal wall muscle mass compared with men. The effects of pregnancy are also known to contribute to haematoma germination. Despite a paucity of evidence, information technology has been suggested that the obese are at risk of developing complicated abdominal wall haematomas and the presence of increased intestinal fat may predispose to an increased risk of haemorrhage [5].

The adipose tissue of the obese differs from those with a normal BMI and obesity-associated adipose tissue dysfunction is an entity thought to be caused by a combination of inappropriate angiogenesis, localized inflammatory reaction and hypoxia [6].

Specifically, the vascularity of subcutaneous tissue in the obese is aberrant when compared with controls [7]. There is an increase in the number and size of blood vessels in the intestinal wall and in that location are structural alterations in the pocket-sized arteries. These processes are driven by an increase in local vascular endothelial growth factors and angiopoietins [8].

Change in the subcutaneous tissue of the obese is not limited to the vasculature and there are differences in the extra-cellular matrix when compared with the not-obese with the structure of both elastin and collagen affected. Quantification of elastin in one trial showed that adipose tissue from obese individuals had <6% total elastin content compared with ∼12% in lean individuals [9].

As in the elderly where vascular fragility and changes to the subcutaneous tissue surroundings limit the external compression of an abdominal wall haematoma, the aforementioned may be said of the obese. For this reason the tamponade outcome that contributes to the cessation of haemorrhage may be attenuated in obese patients [10].

To summarize, although intestinal wall haematomas are not mutual, they are potentially fatal. The literature makes fiddling reference to the weight or body mass index of this group of patients. Information technology has been shown that there are changes in the vascularity and the extra-cellular matrix in the subcutaneous tissue of the obese. Information technology is thought that the lack of external compression of an abdominal wall haematoma makes haemorrhage more likely. For this reason, the obese appear at greater hazard from this relatively uncommon phenomenon and vigilance is required in this group of patients to ensure their haemodynamic stability and safety.

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