Spontaneous haemorrhage on apixaban masquerading as obstructive cholangitis after heart surgery

Extract

A 73-year-old patient required anticoagulation with apixaban 2.5 mg 2×/day after developing atrial fibrillation early after coronary artery bypass grafting. On the 16th post-operative day, the patient presented with acute, excruciating epigastric and right upper quadrant pain irradiating to the back. Liver and pancreatic enzymes were elevated. Computed tomography excluded a pulmonary embolism and aortic dissection and showed an enlarged gall bladder with radio-dense material and possible microlithiases (Panel A). Magnetic resonance imaging cholangiography showed acute cholecystitis with sludge in the gall bladder, without dilatation of the biliary ducts and no lithiasis. The patient was placed on ceftriaxone and metronidazole and had a favourable course.

He presented with recurrent right upper quadrant symptoms on post-operative day 27. He was septic, with a fever of 38.5°C. Liver and pancreatic enzymes were significantly increased. Magnetic resonance imaging cholangiography showed biliary duct dilatation with sludge obstructing the last 5 cm of the common bile duct (Panels B and C). Endoscopic ultrasound examination didn’t show any lithiases or bile duct obstruction. Laparoscopic cholecystectomy was performed. The gall bladder was extremely tense. Needle-puncture was attempted; however, the material within it was too dense to be aspirated. Old clots were exteriorized under pressure (Panel D). After removing clot and obtaining retrograde bile flow through the cystic duct, cholangiography showed clear bile ducts. The patient had an uncomplicated recovery.