Unusual findings in a patient taking warfarin

A 60-year-old man was admitted with a 48-hour history of left-sided abdominal pain. He was receiving anticoagulation therapy with warfarin for a prosthetic aortic valve. His INR on admission was 4.1. Initial full blood count, urine microscopy and plain abdominal radiographs were normal. He underwent an abdominal computed tomography (CT) scan (figure 1). Within 24 hours the patient developed ecchymoses in the peri-umbilical region, both flanks, and down the left lower limb from the thigh to the lateral aspect of the foot (figure 2). ... The CT scan shows a left-sided retroperitoneal haematoma. Cullen's sign1 was originally described as peri-umbilical ecchymoses in ruptured extra-uterine pregnancy, but has come to be considered a sign of acute haemorrhagic pancreatitis. Grey-Turner described haemorrhagic discolouration of the flanks in acute pancreatitis2 and Fox described discolouration of the thigh due to extraperitoneal haemorrhage.3 These appearances can be caused by a number of other conditions besides acute pancreatitis; for example, Cullen's sign can occur as a result of splenic rupture.4 Retroperitoneal haematoma is an unusual cause of cutaneous haemorrhagic discolouration. Spontaneous retroperitoneal haematoma has been described in anticoagulated patients,5 although it is a rare occurrence when the INR is within the therapeutic range. Discolouration of the foot caused by retroperitoneal haematoma (or any other form of intra-abdominal haemorrhage) has not been previously reported.