Extensive small bowel intramural haematoma secondary to warfarin

Abstract

Intramural haematoma is a rare complication of oral anticoagulant therapy, occurring in 1 in 2500 patients treated with warfarin. This report describes a 71-year-old gentleman who presented with tachycardia, vomiting and abdominal distension on a background of anticoagulation for a metallic aortic valve. He was found to have a supratherapeutic international normalized ratio (INR) of 9.9 with an extensive small bowel intramural haematoma and secondary small bowel obstruction. He was successfully managed non-operatively with fluid resuscitation, INR reversal, bowel rest and nasogastric decompression. The patient's presentation was atypical with a lack of classic symptoms such as abdominal pain. This highlights the importance of considering intramural haematoma as a differential diagnosis for gastrointestinal symptoms in anticoagulated patients.

Case Report: Spontaneous Intramural Hematoma of the Colon Secondary to Low Molecular Weight Heparin Therapy

“…The incidence of bowel hematoma was reported to be 1/2500 per year in patients receiving warfarin, and the incidence is relatively higher in males (Bettler et al, 1983). Limmer and Clement (2017) reported a case of successful conservative treatment of bowel hematoma caused by overdose anticoagulation with warfarin in a 71-year-old man. Shaw et al (2005) reported one case of small-bowel hematoma in a child who received therapeutic doses of LMWH because of deep venous thrombosis.…”

Spontaneous descending colon hematoma due to a rare complication of warfarin therapy: A case report

“…Predisposing factors for spontaneous intramural hematoma include bleeding diathesis, hematological malignancies, vasculitis, chemotherapy, H. Pylori infection, colonic diverticular bleeding, angiodysplasia, or iatrogenic injuries such as endoscopic biopsy. 2 Moreover, in patients with the history of cardiac surgery, myocardial infarction should also be ruled out. 3,8,10 At first instance, making a precise diagnosis of warfarininduced intramural hematoma before doing an invasive approach is difficult and it requires high clinical judgment to prevent unnecessary exploratory surgeries.…”

“…1 It also can present as a rare complication of anticoagulant therapy, especially warfarin. 2 The small intestine is the most common site affected by spontaneous intramural hematoma and intramural hematoma of the colon is really rare. Because of the rarity of spontaneous colon hematoma, often the diagnosis is not suspected.…”

Warfarin Poisoning and Blunt Abdominal Trauma: A Rare Cause of Small Bowel Obstruction

“…Most studies consist of case reports or series. Studies have reported effective non-operative management with nasogastric decompression, bowel rest, and correction of coagulopathy [8,[12][13][14]. A review of the literature revealed two case studies wherein poisoning lead to coagulopathic small bowel hematomas resulting in obstruction.…”