Month-Long Unclotted Hemoperitoneum on Edoxaban Confirmed by Laparoscopy: A Case Report

Direct oral anticoagulants (DOACs) can alter the morphology and time course of intra-abdominal bleeding, yet intraoperative confirmation of prolonged unclotted hemoperitoneum is rarely described. We report a man in his early 70s taking edoxaban for atrial fibrillation who was admitted with acute cholecystitis and underwent percutaneous transhepatic gallbladder drainage (PTGBD). After spontaneous tube dislodgement, he developed hemoperitoneum; computed tomography (CT) showed bloody ascites without organized clots. Edoxaban was withheld for one week and then restarted, and he remained hemodynamically stable without transfusion. Approximately one month later, an elective laparoscopic cholecystectomy revealed a large volume of dark, free-flowing liquid blood throughout the peritoneal cavity, with no fibrin clots or organized hematoma and no active bleeding; the fluid was aspirated, and the postoperative course was uneventful. The findings suggest that factor Xa inhibition, by suppressing thrombin generation and fibrin polymerization, may impede secondary coagulation of blood already leaked into the peritoneal space, allowing intraperitoneal blood to persist in a liquid state for weeks even after hemostasis and temporary drug withdrawal. This case provides laparoscopic evidence that edoxaban-associated hemoperitoneum can remain unclotted for about one month, and it highlights the need for surgeons planning interval procedures in anticoagulated patients to anticipate liquid collections, prepare for early/repeated suction-irrigation, and operate with the expectation that identification of dissection planes and transection lines may be difficult.