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A Case Of Spontaneous Intercostal Artery Hemorrhage
Chang Lee, MD
Providence Portland Medical Center – Portland, OR
Additional Authors: Veronica Schims, MD; Craig Riley, MD
Introduction: Spontaneous intercostal arterial bleeding is rare and usually related to trauma. We describe a patient with a history of cirrhosis and coagulopathy admitted with sepsis who spontaneously developed an expanding extrathoracic hematoma and subsequent hypovolemic shock requiring arterial embolization.
Case Presentation: 50-year-old male with a past medical history of alcoholic liver disease, esophageal varices, chronic coagulopathy, type 2 diabetes and hypertension on lisinopril was admitted to hospital with decreased urine output, dizziness, poor PO intake and lower abdominal discomfort. On exam, blood pressure was 80/50 mmHg and he was encephalopathic with otherwise unremarkable physical exam. Labs showed a normal lactate, sodium 117, hemoglobin 11 g/dL, INR 1.5, elevated creatinine and severe metabolic acidosis. CT abdomen and pelvis showed nonspecific diffuse colitis but no source of infection. His decompensated cirrhosis and acute kidney injury was thought due to poor oral intake and Lisinopril use. He developed worsening renal function and acidosis. His urinary output diminished leading to volume overload. He was then transferred to the intensive care unit for placement of right-sided internal jugular temporary dialysis catheter for initiation of hemodialysis, which was without complications. On hospital day five, he developed a precipitous drop in hemoglobin from 8.7 to 6.0 g/dL and a new right back pain with swelling. A CT chest/abdomen/pelvis revealed a large hematoma along the posterior right hemithorax involving the latissimus dorsi extending from the level of the 1st to 10th rib measuring 30 cm x 5 cm. No reports of trauma and no invasive procedures occurred to explain the hematoma. The patient required multiple transfusions of red blood cells, platelets and fresh frozen plasma and the bleeding, expected to tamponade itself, continued. He underwent emergent arterial embolization with coiling of three intercostal arteries and then successful ultrasound-guided evacuation of the remaining large extrathoracic hematoma.
Discussion: This is a rare case of spontaneous intercostal arterial bleeding. Literature review shows spontaneous intercostal artery hemorrhage is rare. Cases of intercostal artery hemorrhage more commonly involve trauma, and rarer still, associations with neurofibromatosis type 1 and coarctation of the aorta. There is one case report of an incident occurring after hemodialysis, which is the case in this patient. Other case reports include patients with hepatocellular carcinoma, intercostal artery aneurysm while in flight, SLE with antiphospholipid syndrome, Dengue fever, as well as causes entirely unknown. Our patient had underlying liver disease with chronic coagulopathy and mild thrombocytopenia as risk factors for spontaneous bleeding, other considerations included use of low molecular weight heparin or heparin use with hemodialysis, but no inciting factor such as trauma or surgical intervention. When active, uncontrollable bleeding is observed from intercostal arteries, early arterial embolization should be considered.
Graduate Medical Education
Conference / Event Name
Academic Achievement Day, 2020
Providence Portland Medical Center, Internal Medicine Residency, Portland, Oregon
Lee, Chang Min; Schims, Veronica; and Riley, Craig, "A Case Of Spontaneous Intercostal Artery Hemorrhage" (2020). Providence Portland Medical Center Internal Medicine. 18.