Acenocoumarol overdose
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Haemobilia in an elderly patient: case report A 79-year-old woman with cholelithiasis developed haemobilia after an unintentional overdose of acenocoumarol, which she was receiving for atrial fibrillation. She subsequently died. The woman had been treated for chronic heart failure, permanent atrial fibrillation and chronic obstructive pulmonary disease for 5 years. Over this time her medications included the anticoagulant acenocoumarol 4mg daily, but for 5 days immediately before presentation, she had mistakenly taken 12mg daily. She presented with week-long symptoms of dizziness, fatigue, dyspnoea and diarrhoea. She was hospitalised with a cardiac arrhythmia, slight abdominal pain and calf swelling. Her liver was slightly enlarged. An ECG showed atrial fibrillation and ST segment lowering. Her lungs were making wheezing and raling sounds. Tests demonstrated a high INR (20), prothrombin time and prothrombin index. Her bilirubin was also elevated and she had hyponatraemia. Acenocoumarol was discontinued. The woman was initiated on pharmacological treatment and her condition improved. An echocardiogram showed left ventricular dysfunction and atrial enlargement. A Doppler examination demonstrated mild mitral stenosis with regurgitation. Emphysema was visible on a chest x-ray. Nine days after admission, she experienced abdominal pain and a temperature of 39°C. Elevated liver and pancreatic enzymes were symptomatic of liver and pancreas damage. An ultrasound showed an enlarged liver containing enlarged bile ducts. A large gallstone and thick bile were seen inside her gallbladder. Her gallbladder was removed, and blood clots and infected blood were removed from the common bile duct. Following surgery her skin was still visibly yellow and her plasma bilirubin level was high. She experienced recurrent respiratory and urinary infections. On day 59 of hospitalisation, she developed lower limb hemiplegia caused by spinal cord anoxia. An x-ray revealed a vertebral fracture and advanced osteoporosis. She again experienced abdominal pain, and a CT scan showed a spleen abscess. She underwent a splenectomy, afterwards developing acute pancreatic inflammation. After 5 months in hospital, she died from sepsis and subsequent multiple organ failure. Author comment: The patient mistakenly took three tablets of 4mg acenocoumarol daily for 5 days, which might have caused bleeding into the bile ducts. In addition, cholethiasis may infrequently cause haemobilia. The acenocoumarol overdose might have triggered the haemobilia, with a resultant INR of 20. Prystupa A, et al. Haemobilia in the course of acenocoumarol overdosage in patient with cholelithiasis - a case study. Przeglad Lekarski 64: 314-315, No. 4-5, 801093379 2007 [Translated from Polish] - Poland
0114-9954/10/1175-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved
Reactions 27 Oct 2007 No. 1175
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