Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 117956

AbstractCase ReportDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case Series
Year : 2023 | Month : November | Volume : 17 | Issue : 11 | Page : OR10 - OR12 Full Version

Spontaneous Iliopsoas Haematoma in Patients Undergoing Haemodialysis- An Enigma: A Case Series

Published: November 1, 2023 | DOI:
Prajwal Kishore, Prashant G Kedlaya, Anantharam Jairam, Renuka Satish, Shashank Dhareshwar

1. Senior Resident, Department of Nephrology, St. John’s Medical College Hospital, Bengaluru, Karnataka, India. 2. Professor, Department of Nephrology, St. John’s Medical College Hospital, Bengaluru, Karnataka, India. 3. Professor, Department of Nephrology, St. John’s Medical College Hospital, Bengaluru, Karnataka, India. 4. Professor, Department of Nephrology, St. John’s Medical College Hospital, Bengaluru, Karnataka, India. 5. Assistant Professor, Department of Nephrology, St. John’s Medical College Hospital, Bengaluru, Karnataka, India.

Correspondence Address :
Dr. Prajwal Kishore,
Utility Complex, 2nd Floor, St. John’s Medical College Hospital, Bengaluru-560034, Karnataka, India.


Chronic Kidney Disease (CKD) progression is associated with an increased risk of bleeding due to various reasons, some of which are iatrogenic. Bleeding at unusual sites, such as the iliopsoas muscle, is difficult to suspect as awareness about this condition is sparse, and the literature about the reasons for this condition is unclear. Iliopsoas bleed continues to be an enigma, and herein, the authors present a case series of three cases of spontaneous iliopsoas haematoma. The first case was a 64-year-old male with acute coronary syndrome and CKD on dual antiplatelet agents who had an iliopsoas bleed after dialysis. The second patient was a 51-year-old male with end-stage renal disease on Maintenance Haemodialysis (MHD) who bled into the iliopsoas after anticoagulation for Coronavirus Disease-2019 (COVID-19) related illness. The third patient was a 52-year-old female who had a Catheter-Related Bloodstream Infection (CRBSI) and Atrial Fibrillation (AF) requiring anticoagulation, and she developed an abdominal wall haematoma extending upto the iliopsoas. The authors highlighted the sudden occurrence, challenges in diagnosis and management of iliopsoas bleed in CKD, with a stress on the careful use of anticoagulation.


Anticoagulation, Apixaban, Bleeding, Chronic kidney disease, Renal replacement therapy

Iliopsoas haematoma is a rare complication associated with trauma, anticoagulation therapy, and haemorrhagic diathesis (1). The reported incidence of retroperitoneal haematoma varies from 0.1 to 0.6% (2). Old age, the use of anticoagulation, and CKD are known risk factors (2). The clinical presentation may vary from mild pain to abrupt shock leading to cardiovascular collapse, which, if not diagnosed early, leads to adverse outcomes (3). The exact mechanism is not known, but hypotheses include small vessel diffuse arteriosclerosis, forceful muscle strain, and heparin-induced immune microangiopathy (3). Spontaneous iliopsoas haematoma in haemodialysis patients often goes unnoticed. The present series reports three cases of symptomatic spontaneous iliopsoas haematoma that required specific management.

Case Report

Case 1

A 64-year-old male was admitted to the Department of Nephrology with complaints of bilateral pedal oedema lasting seven days and left-sided anginal chest pain for the past two days. The patient also had dyspnoea associated with a dry cough, which progressed to orthopnoea over the next two days. He has been diabetic for the past 20 years with a history of proliferative diabetic retinopathy. For the last year, he had been on dual antiplatelet agents (aspirin 75 mg and clopidogrel 75 mg once daily) for ischaemic heart disease (left ventricular ejection fraction 35%). The patient was also diagnosed with CKD-diabetic nephropathy during the same period, with a creatinine level of 2.5 mg/dL. Clinical examination revealed findings of accelerated hypertension with a blood pressure of 200/120 mmHg and acute pulmonary oedema. The patient was hypoxic and required oxygen support. Investigations revealed a haemoglobin level of 8.1 g/dL, serum creatinine of 3.2 mg/dL, platelet count of 1.75 lacs/cumm, and normal coagulation profile (prothrombin time 11.4 seconds, control 12 seconds, Activated Partial Thromboplastin Time (APTT) 29.4 seconds, control 30 seconds).

The patient was initiated on haemodialysis via a right femoral non tunneled catheter and underwent three sessions of haemodialysis. The patient’s Electrocardiogram (ECG) showed T inversion in lateral leads with serial elevated troponin I. A diagnosis of acute coronary syndrome- non ST segment elevation myocardial infarction was made, and he was started on anticoagulation (heparin 5000 units subcutaneous every six hours). A coronary angiogram was planned; however, the patient developed severe pain in both thighs with a drop in haemoglobin of 2 g/dL. A Computed Tomography (CT) scan showed bilateral iliopsoas haematoma (left more than right, approximately 100 cc). Heparin was discontinued, and he received one unit of packed red cell transfusion, as well as cryoprecipitate. The patient underwent saline haemodialysis during the hospital stay and received analgesics for pain (tablet paracetamol 650 mg thrice daily for five days and tramadol 50 mg IV when required). Due to personal reasons, the patient was discharged against medical advice with a single antiplatelet agent as he had acute coronary syndrome, and he then expired at his residence four days after the discharge.

Case 2

A 51-year-old male was admitted to the Department of Nephrology with the chief complaint of intermittent low-grade fever for the past six days. He also experienced cough with scanty mucoid expectoration and dyspnoea. There was no history of chest pain. The patient had been on two classes of antihypertensive drugs for five years and was a known case of CKD on MHD for three years. Due to multiple access failures, the patient was undergoing haemodialysis through a right femoral tunneled catheter. He had been taking a single antiplatelet, aspirin 75 mg, once daily for three years (reason unknown). Physical examination revealed a blood pressure of 130/80 mmHg, pallor, oedema, tachypnoea, hypoxia, and bibasal crepitations. The patient tested positive for Coronavirus Disease-2019 (COVID-19) by Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) and was treated with nasal oxygen, anticoagulation (heparin 5000 units subcutaneous twice daily), and steroids (inj. hydrocortisone 100 mg twice daily). Aspirin was continued, and he recovered from COVID-19 illness. On the 19th day of admission, after a session of haemodialysis (with standard anticoagulation), the patient developed severe pain over the left lower abdomen, radiating to the lower limb, and experienced pain on flexion of the left hip. His haemoglobin had dropped by 1.5 g/dL (from 7.5 g/dL to 6 g/dL), platelet count was 1.92 lacs/cumm, and coagulation profile was normal (prothrombin time 12.5 seconds, control 12 seconds, APTT 28.3 seconds, control 30 seconds). There was no haemodynamic instability. Ultrasound followed by Computed Tomography (CT) scan [Table/Fig-1,2] revealed a haematoma in the left ilacus muscle measuring approximately 11.7×7.8×6.8 cm (310 cc). Aspirin and heparin were stopped. The patient underwent saline haemodialysis and required three units of packed red cell transfusion. Haemoglobin and Packed Cell Volume (PCV) were monitored daily until the haemoglobin stabilised (haemoglobin at discharge was 8 g/dL). Pain was managed with analgesia (paracetamol 650 mg for five days and tramadol 50 mg as required). The patient responded well to this conservative management and had an uneventful recovery. On follow-up, he continued to remain on MHD with stable haemoglobin.

Case 3

A 52-year-old female was admitted to the Department of Nephrology with the chief complaint of high-grade fever with chills, cough with mucoid expectoration, and dyspnoea on exertion for the past two days. She also had a history of retrosternal chest pain for one day, associated with palpitations. The patient had been hypertensive for the past year and required three classes of antihypertensive drugs. She was recently diagnosed with CKD due to chronic interstitial nephritis and had initiated haemodialysis via a right temporary Internal Jugular Catheter (IJC) for the last month. On examination, the patient had an irregular pulse rate of 160/minute and BP of 160/100 mmHg. She was tachypneic with a respiratory rate of 22 breaths/minute. Respiratory examination showed bibasal crepitations. The ECG was suggestive of AF with a fast ventricular rate (Table/Fig 3).

Investigations revealed a haemoglobin level of 8 g/dL, total count of 16.8 cumm, serum creatinine of 10.1 mg/dL, serum sodium of 133 meq/L, serum potassium of 5.9 meq/L, and serum calcium of 10.4 mg/dL. The platelet count was 2.93 lacs/cumm, and the coagulation profile was normal (prothrombin time 13.2 sec, control 12 sec, APTT 28.7 sec, control 30 sec). The patient was treated with urgent haemodialysis via a right IJC. For AF, she was anticoagulated with heparin 5000 units subcutaneous for five days, followed by apixaban 2.5 mg twice daily, and received amiodarone infusion for two days, after which the AF reverted. The patient was also diagnosed with CRBSI as the blood culture from the peripheral line and catheter was positive. Hence, the right IJC was removed after 11a session of haemodialysis, and she was treated with intravenous antibiotics (inj. vancomycin 1gm i.v. every 72 hours and inj. amikacin 500 mg i.v. every 48 hours, total of 5 doses each), after which the patient became afebrile. On the third day of admission, the left brachiocephalic AV Fistula (AVF) was cannulated; however, she developed pain and swelling at the AVF site suggestive of haematoma. Therefore, a left femoral non tunneled catheter was secured (dose of heparin was withheld preprocedure). On the seventh day (two days after starting apixaban-patch test not done), she developed a sudden onset of pain and swelling in the right lower abdomen with hypotension (BP 80/50 mmHg). A drop in haemoglobin by 4 g/dL (from 8 g/dL to 4.2 g/dL) was noted. The patient was managed with discontinuation of apixaban, four units of packed red cell transfusion, and required inotropic support (noradrenaline). CT scan showed a large intramuscular haematoma (Table/Fig 4) involving the right lateral chest wall, lateral abdominal wall, extending upto the level of the right iliac bone (600 cc) with no active contrast extravasation. In view of haemodynamic instability, she was planned for intervention. However, the procedure was deferred as the patient showed improvement with blood transfusion and was off inotropes within the next 48 hours. Daily abdominal girth monitoring was done along with haemoglobin and PCV (haemoglobin stabilised at 8 gm/dL with no further drop). The patient received analgesia for pain (tab paracetamol 650 mg thrice daily for five days and inj. tramadol 50 mg i.v. when required) and underwent saline haemodialysis. The patient improved with conservative management and had an uneventful recovery. She had stable haemoglobin levels during her subsequent follow-up after 10 days.


Iliopsoas haematoma is a rare complication associated with trauma, anticoagulation therapy, and haemorrhagic diathesis (1). The incidence of spontaneous retroperitoneal haematoma in patients on anticoagulation is 0.1-0.6%, irrespective of kidney disease. Risk factors include elderly individuals, anticoagulation therapy, CKD, and those with bleeding abnormalities (2). The present case series reported three cases of symptomatic spontaneous iliopsoas haematoma that warranted intervention in the form of blood transfusion, and one patient had haemodynamic instability requiring vasopressors.

Acute onset abdominal or thigh pain was the presenting symptom in index patients. In a case report by AbdAlgayoum RTA et al., the patient had abdominal and thigh pain with circulatory collapse (3). Other signs described include Grey Turner sign and Cullen sign (ecchymotic lesions in the flank and periumbilical area, respectively) (3). Due to compression anywhere along the course of the femoral nerve, patients can present with weakness of the iliopsoas, paralysis of the quadriceps, paresthesia in the anteromedial aspect of the lower extremity, and loss of the knee jerk (4). Patients with CKD present a dilemma in that they are simultaneously prothrombotic and also have an increased bleeding tendency, especially in patients undergoing haemodialysis due to the use of anticoagulation. Pathophysiological factors attributable to this bleeding risk are uremic platelet dysfunction, anaemia, use of antiplatelet agents, as well as anticoagulation. Iliopsoas haematoma should be suspected when they present with an acute onset of abdominal or thigh pain with difficulty in flexing the hip, as these might be the only presenting complaints along with a drop in haemoglobin (2),(3).

All three patients presented with a cough due to infection/pulmonary oedema. Vigorous cough reflex could have caused minor trauma to the microcirculation and possibly lead to spontaneous bleeding in anticoagulated patients (1),(2). Literature review suggests that the pathophysiology of spontaneous retroperitoneal bleeding is due to diffuse occult vasculopathy and arteriosclerosis of the small vessels, which may be friable. Once bleeding starts and the haematoma expands at the microvascular level, the large vessels are stretched and ruptured (5),(6). In a study done by Berna JD et al., they attributed the causes to anticoagulation-induced immune microangiopathy and minor trauma to the microcirculation by vomiting/coughing in the presence of anticoagulation (7).

Two of the patients were on heparin, and one was on apixaban before the onset of spontaneous bleeding. In a review article by Hughes S et al., in patients with advanced renal failure receiving a therapeutic dose of unfractionated heparin, there is impaired clearance due to saturation of reticuloendothelial cells. Due to interpatient variability of accumulation, there can be an unpredictable anticoagulant response (8). Apixaban is highly protein-bound, and several studies suggest it can accumulate in CKD and is poorly dialyzable [9,10]. The use of anticoagulation in advanced CKD and patients on haemodialysis is a challenge, as evidence from large randomised controlled trials is limited. Guidelines for the use of anticoagulation in the general population cannot be extrapolated for advanced CKD as the risk of bleeding is very high (11). The choice of anticoagulation must be individualised, and it is preferable to use unfractionated heparin as it has a short duration of action, and its effects are easily reversed with protamine.

All three patients were managed conservatively with blood products and supportive care, and none required endovascular intervention. Vital signs should be closely monitored along with frequent haemoglobin and PCV monitoring. Haemodynamic instability with a persistent drop in haemoglobin would warrant an endovascular procedure. In a study done by Llitjos JF et al., and Artzner T et al., 31% and 53% of patients required endovascular or surgical intervention, respectively (2),(12). Early detection of haematoma with timely cessation of anticoagulation might have helped us to avoid endovascular interventions in two patients. If conservative measures fail or the patient is unstable, endovascular selective intra-arterial embolisation or deployment of stent-grafts over the punctured vessel is the treatment of choice. Open surgical repair should be reserved for cases when there is a failure of both conservative and endovascular procedures (13).


The present case series of iliopsoas bleed in CKD highlights the increased risk of spontaneous iliopsoas haematoma associated with the use of anticoagulation in patients on haemodialysis. The choice and dose of anticoagulation should be individualised. It is preferable to use short-acting and easily reversible anticoagulation. A high index of suspicion is required for patients presenting with pain and a drop in haemoglobin for early detection of iliopsoas haematoma and to avoid potentially fatal sequelae. There is a need for larger randomised controlled trials to evaluate the use of anticoagulation in advanced CKD.


Tavone AM, Giuga G, Attanasio A, Petroni G, Mauriello S, Cordova F, et al. A rapid fatal outcome of iliopsoas hematoma: Clinical and autopsy findings. J Investig Med High Impact Case Rep. 2022;10:23247096221111760. [crossref][PubMed]
Llitjos JF, Daviaud F, Grimaldi D, Legriel S, Georges JL, Guerot E, et al. Ilio-psoas hematoma in the intensive care unit: A multicentric study. Ann Intensive Care. 2016;6(1):01-06. [crossref][PubMed]
AbdAlgayoum RTA, Hassan Z, Singapori M, Khanchandrani N. Spontaneous psoas hematoma secondary to anticoagulation. Consultant. 2022;62(1):e17-18.
DeBolt WL, Jordan JC. Femoral neuropathy from heparin hematoma. Report of two cases. Bull Los Angeles Neurol Soc. 1966;31(2):45-50.
Torres GM, Cernigliaro JG, Abbitt PL, Mergo PJ, Hellein VF, Fernandez S, et al. Iliopsoas compartment: Normal anatomy and pathologic processes. Radiographics. 1995;15(6):1285-97. [crossref][PubMed]
Qanadli SD, El Hajjam M, Mignon F, Bruckert F, Chagnon S, Lacombe P. Life- threatening spontaneous psoas haematoma treated by transcatheter arterial embolization. Eur Radiology. 1999;9:1231-34. [crossref][PubMed]
Berna JD, Zuazu I, Madrigal M, Garcia-Medina V, Fernandez C, Guirado F. Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdominal Imaging. 2000;25:230-34. [crossref][PubMed]
Hughes S, Szeki I, Nash MJ, Thachil J. Anticoagulation in chronic kidney disease patients-the practical aspects. Clin Kidney J. 2014;7(5):442-49. [crossref][PubMed]
Steuber TD, Shiltz DL, Cairns AC, Ding Q, Binger KJ, Courtney JR. A multicenter analysis of factors associated with apixaban-related bleeding in hospitalized patients with end-stage renal disease on hemodialysis. Ann Pharmacother. 2017;51(11):954-60. [crossref][PubMed]
Jha VK, Jairam A, Mahapatra D. Newer oral anticoagulant in chronic kidney disease: What we should know. J Assoc Physicians India. 2019;67(11):60-65.
Aursulesei V, Costache II. Anticoagulation in chronic kidney disease: From guidelines to clinical practice. Clin Cardiol. 2019;42(8):774-82. [crossref][PubMed]
Artzner T, Clere-Jehl R, Schenck M, Greget M, Merdji H, De Marini P, et al. Spontaneous ilio-psoas hematomas complicating intensive care unit hospitalizations. PLoS One. 2019;14(2):e0211680. [crossref][PubMed]
Chan YC, Morales JP, Reidy JF, Taylor PR. Management of spontaneous and iatrogenic retroperitoneal haemorrhage: Conservative management, endovascular intervention or open surgery? Int J Clin Pract. 2008;62(10):1604-13.[crossref][PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/65860.18702

Date of Submission: Jun 07, 2023
Date of Peer Review: Jul 25, 2023
Date of Acceptance: Sep 29, 2023
Date of Publishing: Nov 01, 2023

• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Jun 08, 2023
• Manual Googling: Sep 25, 2023
• iThenticate Software: Sep 27, 2023 (5%)

ETYMOLOGY: Author Origin


JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)