Spontaneous Perigastric Hematoma and Hemoperitoneum Associated With Rivaroxaban Therapy: A Case Report and Review of the Literature

Spontaneous hemoperitoneum is a rare but potentially life-threatening complication of direct oral anticoagulant (DOAC) therapy.We report the case of a 59-year-old man receiving long-term rivaroxaban for atrial flutter, previously treated with tricuspid isthmus ablation, who was admitted for atypical chest pain and subsequently developed acute abdominal pain during observation.Contrast-enhanced computed tomography (CT) revealed spontaneous intra-abdominal hemorrhage presenting as a perigastric hematoma with hemoperitoneum, with the perigastric component measuring 96 mm × 58 mm, without active contrast extravasation or an underlying focal lesion.Throughout the admission, the patient remained hemodynamically stable, with no active contrast extravasation on CT and only a moderate decline in hemoglobin levels, from 14.8 g/dL at admission to a nadir of 12.3 g/dL, without requiring transfusion.He was managed with interruption of rivaroxaban and close clinical and biological monitoring alone, with full recovery and no invasive procedure required.A focused review of six comparable published cases of rivaroxaban-associated spontaneous intra-abdominal hemorrhage showed that most required invasive intervention for hemodynamic instability, underscoring the favorable outcome in this hemodynamically stable patient and supporting an individualized, severity-adapted approach to management.The case is notable for the combination of a sizeable perigastric hematoma, moderate hemoperitoneum, absence of active extravasation, hemodynamic stability, and successful non-invasive management.This combination appears to be rarely reported among previously published rivaroxaban-associated intra-abdominal hemorrhages, which predominantly required invasive intervention.