Spontaneous Hemo-Mediastinum Following Laparoscopic Appendectomy: A Case Report

Introduction

Hemo-mediastinum is a rare condition that can result from various underlying causes, such as iatrogenic factors, trauma, malignancy, bleeding disorders, or hemorrhage from mediastinal organs [1,2]. Spontaneous hemo-mediastinum can occur due to bleeding disorders such as hemophilia, anticoagulant use, and connective tissue disorders, or idiopathically, especially following a sudden increase in intra-thoracic pressure from activities such as coughing or sneezing, or from sudden hypertension [3,4]. In clinical practice, mediastinal hematomas are typically a consequence of thoracic trauma or a ruptured aortic aneurysm, while spontaneous, non-traumatic cases are rare [1,2].

The typical clinical presentation includes chest pain, dyspnea, and hemoptysis. Some patients only present with symptoms linked to extrinsic compression of the airways or esophagus [4,5]. Computed tomography (CT) is the preferred diagnostic tool, and treatment focuses on treating the underlying cause and controlling hemorrhage when present. Management may involve urgent surgical intervention or endovascular embolization for hemodynamically stable patients [5]. We report an unusual case of spontaneous hemo-mediastinum in a 65-year-old man with a history of mixed connective tissue disease and chronic cough who developed acute chest symptoms following an uncomplicated laparoscopic appendectomy. We report this case to highlight an unrecognized risk of intra-thoracic hemorrhage following laparoscopic procedures in patients with pulmonary comorbidities. To our knowledge, this is the first reported case of post-appendectomy hemo-mediastinum in a patient with pulmonary comorbidities.

Case Report

A 65-year-old man with a medical history of interstitial lung disease due to undifferentiated connective tissue disorder, mild coronary artery disease, gastroesophageal reflux disease, chronic post-nasal congestion, chronic cough, and chronic pleural effusion status after pleurodesis was admitted to the general surgery service for appendicitis, for which he underwent an uncomplicated laparoscopic appendectomy. The appendix was found to be gangrenous with focal perforation.

During recovery in the post-anesthesia care unit (PACU), he developed acute right chest pain and hemoptysis, followed by hypotension and tachycardia. Evaluation included chest X-ray, EKG, focused assessment with sonography for trauma (FAST) exam, and contrast-enhanced chest CT. The EKG showed no ST elevation or any other abnormalities. Hemoglobin had dropped from 16.2 g/dL preoperatively to 13.2 g/dL. The chest X-ray showed upper-mediastinal widening (Figure 1). Contrast-enhanced CT chest showed a large right upper-mediastinal hematoma with active extravasation of uncertain origination site (Figures 2, 3).

Due to worsening hypotension, a massive transfusion protocol was initiated. The patient received 1 unit of whole blood and IV fluid boluses, which stabilized his blood pressure. Given the ongoing hemodynamic instability, he was urgently transferred to the hybrid operating room for IR evaluation and management.

Angiography identified active hemorrhage originating from branches of the supreme intercostal artery. Sub-selective angiography using a Renegade microcatheter identified active bleeding from a branch, likely the second intercostal artery (Figure 4). Two Hilal coils were used for embolization, and hemostasis was confirmed through angiography. The microcatheter was then repositioned into the costo-cervical trunk, and angiography revealed active bleeding from a second branch of the supreme intercostal artery. Due to the distal location and small size of the vessel, coil embolization was not feasible; instead, cyanoacrylate glue mixed with lipiodol (1: 5 ratio) was used to embolize the second bleeding artery and the residual costo-cervical trunk. Completion angiography of the right subclavian artery confirmed successful embolization and no active bleeding.

The patient was admitted to the critical care unit (CCU), intubated, and sedated. Serial CT scans demonstrated a stable hematoma in the right chest without any active bleeding, but with progressive right-lung consolidation. The next day, due to persistent hypotension and intermittent airway bleeding, he was taken back to IR for a right bronchial artery angiogram. The angiogram showed an irregular segment, likely the source of hemoptysis; this was embolized with glue (Figure 5).

Video bronchoscopy was performed in the same session, revealing no abnormalities or active bleeding. Due to concerns for compression-related tamponade physiology, he underwent video-assisted thoracoscopic surgery for evacuation of the hematoma. The procedure was converted to open thoracotomy by the cardiothoracic surgery team due to extensive adhesions. Hematoma evacuation, washout, and lysis of adhesions were performed, and 3 right-sided chest tubes were placed for drainage. The patient was returned to the CCU, where he was intubated and sedated. As he began to improve, he was weaned from mechanical ventilation 2 days after the thoracotomy operation; the chest tubes were removed in a staged manner. He was discharged home 10 days after admission, with continued recovery.

Discussion

In this case report, we present a rare occurrence of intra-thoracic bleeding in the form of hemo-mediastinum following a laparoscopic appendectomy, leading to a massive mediastinal hematoma and hemodynamic instability. Intra-thoracic bleeding following laparoscopic procedures is uncommon.

Spontaneous hemo-mediastinum is often associated with conditions that elevate intra-thoracic pressure, such as coughing, sneezing, or sudden hypertension [1,2]. Our patient had a history of chronic cough and interstitial lung disease, which likely contributed to increased intra-thoracic stress and vessel fragility, predisposing him to spontaneous mediastinal hemorrhage. Furthermore, the presence of pleural adhesions and chronic pleural effusion might have complicated his intra-thoracic anatomy, increasing his susceptibility to bleeding during or after surgery.

The patient’s presentation with chest pain, hemoptysis, hemoglobin drop, and widening of mediastinal shadow was highly suggestive of bleeding in the thoracic cavity. While it is uncommon to associate laparoscopic appendectomy with such a condition, its occurrence after the surgery in the PACU prompted immediate resuscitation and timely interventions, ultimately saving the patient’s life. The initial management consisted of blood transfusion, urgent imaging to confirm the diagnosis, and hemorrhage control.

Similar to the approach used in traumatic hemo-thorax cases, which are frequently treated with trans-arterial embolization [6], our case was first managed with IR to control the bleeding, but due to persistent signs of tamponade physiology, he ultimately required thoracotomy with hematoma evacuation and chest tube placement.

To our knowledge, this is the first reported case of spontaneous hemo-mediastinum following laparoscopic appendectomy in a patient with pulmonary comorbidities. Our report emphasizes the importance of considering potential complications in patients with pre-existing conditions that can predispose them to bleeding, and the need for a timely, multi-disciplinary approach to improve patient outcomes.

Conclusions

This case report presents the first known case of post-appendectomy intra-thoracic bleeding in the form of hemo-mediastinum, emphasizing the need for heightened awareness of potential unusual complications in patients with predisposing conditions. Even routine procedures can present unexpected challenges, particularly in vulnerable patient populations.