Spontaneous intra-peritoneal bleeding secondary to warfarin, presenting as an acute appendicitis: a case report and review of literature

A 41 year-old female patient who was on warfarin for prophylaxis following the previous episode of pulmonary embolism, presented to the Casualty with the typical symptoms of an acute appendicitis. During operative intervention, we found it to be the spontaneous intra-peritoneal bleeding secondary to warfarin. The patient recovered well following the operation.We recommend the use of the radiological investigations in all the cases of acute abdomen who are on warfarin even if the INR is within the therapeutic range.Warfarin is a coumarin anti-coagulant, widely used for the therapeutic and prophylactic anti-coagulation. Although it is considered as a life saving medicine, it is associated with the several significant adverse effects. Intra-peritoneal bleeding is one of the complications, usually following trivial trauma. There are only very few reported cases of the spontaneous haemoperitoneum in English literature without any evident cause [1,2]. Spontaneous onset of the intra-peritoneal bleeding due to warfarin therapy is also exceptional. We report a case of the spontaneous intra-peritoneal bleeding secondary to warfarin therapy, mimicking the signs and symptoms of an acute appendicitis in a 41-year old Caucasian female, for the first time in English literature. We strongly recommend the consideration of this rare complication in the differential diagnosis of all the cases of acute abdomen in patients who are on warfarin therapy regardless of INR levels, especially in presence of anaemia and tachycardias. We also emphasize the use of the radiological investigations in such cases to achieve the diagnosis to avoid unnecessary surgical intervention.A 41 year-old Caucasian female patient was referred to us by general practioner (G.P.) with 2-day history of the migratory abdominal pain. Initially, the pain was constant and dull in the peri-umbilical region, which later became sharp and localised in the right iliac fosssa. She also complained of four episodes of vomiting