Intramural hematoma of the gastrointestinal tract

Small bowel intramural hematoma caused by warfarin: case report and literature review

BACKGROUND

Intramural hematoma of the small bowel is a rare yet acute gastrointestinal condition typically linked with impaired coagulation function, often posing diagnostic challenges. It is principally encountered in patients undergoing prolonged anticoagulant therapy, specifically warfarin.

CASE PRESENTATION

We reported a case of intramural hematoma associated with warfarin use. The patient was admitted to hospital with abdominal pain and had received anticoagulant therapy with warfarin 2.5 mg/day for 4 years. Laboratory examination showed decreased coagulation function, abdominal CT showed obvious thickening and swelling of part of the jejunal wall, and abdominal puncture found no gastroenteric fluid or purulent fluid. We treated the patient with vitamin K and fresh frozen plasma. The patient was discharged after the recovery of coagulation function. Then we undertaook a comprehensive review of relevant case reports to extract shared clinical features and effective therapeutic strategies.

CONCLUSION

Our analysis highlights that hematoma in the small intestinal wall caused by warfarin overdose often presents as sudden and intense abdominal pain, laboratory tests suggest reduced coagulation capacity, and imaging often shows thickening of the intestinal wall. Intravenous vitamin K and plasma supplementation are effective non-surgical strategies. Nevertheless, in instances of severe obstruction and unresponsive hemostasis, surgical resection of necrotic intestinal segments may be necessary. In the cases we reported, we avoided surgery by closely monitoring the coagulation function. Therefore, we suggest that identifying and correcting the impaired coagulation status of patient is essential for timely and appropriate treatment.

A Case of Direct-Acting Oral Anticoagulant-Induced Intramural Colon Hematoma Successfully Treated by Laparoscopic Surgery

Intramural intestinal hematoma is a rare disease, one of the triggering factors of which is the use of anticoagulants. In previous reports, most patients were on treatment with warfarin. Herein, we report a case of direct-acting oral anticoagulant (DOAC)-induced intramural hematoma of the ascending colon in a patient refractory to conservative treatment and required laparoscopic right hemicolectomy. An 80-year-old male patient with a history of atrial fibrillation and cerebral infarction, on treatment with apixaban, was brought to our hospital with the chief complaints of abdominal pain, vomiting, and melena. Imaging revealed the cause of symptoms to be intestinal obstruction caused by a mass lesion on the wall of the ascending colon. We initially opted for conservative treatment with discontinuation of apixaban and insertion of an ileus tube. Intestinal dilatation findings showed improvement; however, subsequent imaging examinations did not reveal the shrinkage of a lesion in the ascending colon. If the mass was not removed, recurrence of bowel obstruction symptoms was expected, so we decided to perform surgical intervention. A laparoscopic right hemicolectomy was performed, and an intramural hematoma of the ascending colon was diagnosed based on the excised specimen. He needed a blood transfusion for anemia but was discharged on postoperative day 14 with no other complications. DOACs are now widely used in patients with atrial fibrillation, and the risk of bleeding as a side effect is extremely low compared to conventional anticoagulants, including warfarin. However, when abdominal pain occurs, as in the present case, an intramural hematoma should be considered in the differential diagnosis. There is no established treatment plan for intestinal intramural hematoma. Although conservative treatment is effective in some cases, it is difficult to evaluate the risk of bleeding associated with DOACs using coagulation tests. Even if conservative treatment is selected, it is essential to determine surgical resection, if necessary, based on the clinical course and imaging and blood test findings.

Systemic AL amyloidosis with multiple submucosal hematomas of the colon: a case report and literature review

Amyloid light-chain (AL) amyloidosis rarely causes colorectal submucosal hematoma. A 76-year-old man presented with a complaint of bloody stool. An initial colonoscopy revealed ulcerative lesions in the descending colon, leading to a diagnosis of ischemic colitis. One month later, he presented with cardiac failure, suspected cardiac amyloidosis, and underwent a second colonoscopy. Although it revealed multiple ulcerative lesions from the ascending to transverse colon, biopsy samples did not confirm amyloid deposition. He underwent a third colonoscopy 3 weeks later due to recurrent bloody stool. It showed multiple submucosal hematomas from the ascending to descending colon concomitant with ulcerative lesions in the descending colon and multiple elevated lesions in the sigmoid colon. Biopsy samples confirmed amyloid deposition. Using a systemic search, multiple myeloma with AL amyloidosis was diagnosed. Colorectal submucosal or intramural hematomas are conditions usually encountered in trauma, antithrombotic use, or coagulation disorders. Based on our review of the literatures, we identified several differences between colorectal intramural hematoma caused by amyloidosis and those caused by other etiologies. We believe that amyloidosis should be considered when relatively small and multiple colorectal hematomas, not restricted to the sigmoid colon, and with concomitant findings of erosions and ulcers, are observed.

A Rare Case of Traumatic Colonic Intramural Hematoma in Saudi Arabia

Colonic intramural hematomas are rarely encountered clinically. They are most commonly caused by blunt trauma to the abdomen. Diagnosis is usually reached by a combination of a detailed history, physical examination, and radiological investigations. A 14-year-old female patient presented to the emergency department complaining of abdominal pain with a history of a go-karting accident. Upon physical examination, the patient was tachycardic and hypertensive, with right-side abdominal tenderness and fullness. After going through routine radiological investigations, a computed tomography scan showed a large intramural hematoma of the ascending colon measuring around 7.7 x 8.4 x 2 cm. The patient was admitted for conservative management. Throughout her admission, serial examinations were performed, which showed improvement in the patient's condition and the size of the hematoma. The patient was discharged in a stable condition after showing good recovery. Following up with the patient a month later, she was in good condition with no active complaints, and an ultrasound was done that revealed complete resolution. To our understanding, this report of colonic intramural hematoma caused by the unusual etiology of the go-karting accident, which was successfully managed conservatively, adds significantly to the literature.

A Rare Case of Gastric Intramural Hematoma Secondary to Hemorrhagic Pancreatitis

Gastric intramural hematoma (GIH) is a contained hemorrhage located within the layers that comprise the wall of the stomach. It is a rare condition that has a variety of etiologies. Pancreatitis-induced GIH is an even rarer phenomenon, with only a handful of documented cases in the medical literature. In the current case, a patient presented with chronic abdominal pain for the past two months, with an acute worsening of symptoms. CT imaging confirmed a large, stable GIH with concomitant pancreatitis, likely alcohol-induced. Diagnostic laparoscopy was performed in response to worsening hemodynamic status, which confirmed hemorrhagic pancreatitis as the likely cause of the GIH formation. Jackson-Pratt (JP) drains were placed, and the patient was subsequently discharged. The patient returned one month later with an acute exacerbation of pancreatitis; however, interval improvement of the GIH was observed. The patient was transferred to outpatient care for continued conservative treatment without any further return visits.

Hemorrhagic shock due to ruptured idiopathic intramural hematoma of the sigmoid colon-An autopsy case report

We describe herein an autopsy case involving fatal hemorrhagic shock due to idiopathic sigmoid colonic intramural hematoma rupturing into the abdominal cavity. Antemortem computed tomography revealed a mass lesion in the sigmoid colon and a large amount of hemoperitoneum. On forensic autopsy, intramural hematoma of the sigmoid colon with ruptured serosa was identified, while the mucosa remained intact. Microscopically, hematomas were apparent, mainly in the muscularis propria. We diagnosed the cause of death as hemorrhagic shock due to idiopathic intramural hematoma of the sigmoid colon rupturing into the abdominal cavity. Although the patient had been receiving peritoneal dialysis, no relationship was identified between dialysis catheters and sigmoid colon intramural hematoma rupture. On computed tomography, the mass lesion was initially considered a submucosal neoplastic lesion or endometriotic lesion. Intramural hematoma should be considered as a differential diagnosis.

Colonic Intramural Hematoma in a Cat: A Case Report

Colonic intramural hematoma is a rare condition in humans and companion animals. Its clinical presentation in cats has not previously been reported. An 8-year-old male American shorthair cat presented with acute onset of constipation and anorexia for 3 days. Laboratory examination indicated mild elevation of alanine aminotransferase, globulin, and total protein levels. Complete blood count was normal. Radiographs revealed a soft tissue opacity mass located caudodorsally to the urinary bladder, causing narrowing of the descending colonic lumen. Sonography showed a heteroechogenic intraluminal mass containing liquefied content between the submucosal and muscular layers of the descending colon. On computed tomographic images, the mass contained two different attenuated contents with an interface. Colonoscopy was then performed for intestinal biopsy, and the contents observed in the intraluminal mass were drained via surgical evacuation and considered as blood clots. Supportive medical treatment, including antibiotics and fecal softener, was administered, and the clinical signs resolved uneventfully. Mild chronic proctitis without apparent malignancy was confirmed histopathologically, and no recurrence was observed after more than 14 months, and thus a colonic intramural hematoma was presumptively diagnosed. The information provided by multimodal imaging of the mass was essential for the diagnosis and determination of the treatment in this case.

Perspectives and Management Strategies for Acute Colonic Intramural Hematoma

Acute intramural hematoma of the colon is a rarely encountered clinical condition with diverse precipitating factors. Different acute and chronic complications emerge following hematoma formation, mandating high clinical suspicion for early diagnosis and optimum management. CECT represents the cornerstone for the proper demonstration of colonic hematomas and possible detection of complications as well as the underlying etiology. There are multiple strategies for management of intramural hematoma and treatment should be tailored according to the etiology and the clinical condition of the patient, reserving surgical intervention for unstable or complicated cases. Endoscopic management of colonic hematomas offers a promising minimally invasive modality with potential safety and efficacy.

Traumatic Acute Colonic Intramural Hematoma: A Rare Entity and Successful Expectant Approach

Acute intramural hematoma in colon is a rare presentation following trauma. There are reports in literature of acute colonic hematoma following trauma, warfarin intake and in patient with coagulation disorders. In traumatic acute colonic intramural hematoma, most of the reported cases were managed surgically. Very few cases were successfully managed conservatively. We present a case of 28-year-old male who presented to the surgical emergency after two days of road traffic accident. After relevant investigations, he was found to have intramural hematoma of ascending colon, which was managed conservatively.

A Case of Gastric Intramural Hematoma Caused by Anisakis Infection

A sixty-year-old lady admitted complaining of epigastric pain and hematemesis. On admission, esophagogastroduodenoscopic examination revealed ruptured intramural hematoma on the antrum of stomach. Eight days later, follow-up EGD showed improving ruptured intramural hematoma and one anisakis larva. Therefore, the gastric intramural hematoma was considered to be caused by anisakis infection. She recovered after ten days of conservative treatment.

Intramural Hematoma Causing Hematochezia After Colonoscopy With Polypectomy

Intramural hematoma of the colon is a rare complication of colonoscopy. We present a case of a 78-year-old woman on warfarin who presented with hematochezia and hypotension due to intramural hematoma of the sigmoid colon after colonoscopy with polypectomy of small polyps in the right colon.

Idiopathic intramural hematoma of the right colon. A case report and review of the literature

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A very rare case of spontaneous colon hematoma has been reported.

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The rarity of our case of colon hematoma is due to the fact that it is idiopathic.

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The topic is still under discussion in the Literature since the pathophysiology remains still unknown.

Introduction

Intestinal hematoma is usually observed after an abdominal trauma or in patients treated with anticoagulant therapy. Conversely, idiopathic bowel hematoma is very rare, being colon involvement sporadic with few reports in the Literature.

Presentation of case

The Authors report a case of idiopathic spontaneous large bowel hematoma. A 48-year-old man was admitted for a thoraco-abdominal pain and signs of acute abdomen and fever. After ruling out heart diseases, a CT scan revealed a marked thickening of the ascending colon wall, obstructing the bowel lumen. Leukocytosis was observed. In an emergency setting, an explorative laparotomy was performed. Hemoperitoneum and a large hematoma involving the caecum and the ascending colon were detected, together with intramesenteric and retroperitoneal blood effusion. A right hemicolectomy was accomplished. Histopathology confirmed the diagnosis of large bowel hematoma. Post-operative molecular diagnostic testing for coagulative disorders failed to demonstrate any genetic variation associate with hemorrhagic predisposition.

In the post-operative course, the patient experienced a left basal bronco-pneumonia with increased unilateral pleural effusion, successfully treated by a thoracic drain and antibiotic therapy.

Discussion

The reported case and Literature data show that diagnosis of idiopathic colon intramural hematoma is challenging, especially in the emergency setting. Although conservative therapy is the first line treatment, surgery still has an important role when the diagnosis is uncertain, medical treatment fails or a complication, such untreatable bleeding, perforation or occlusion occur.

Conclusion

The Authors report a very rare case of spontaneous intramural hematoma of the right colon. Surgery still has a role in selected cases.

Overlooked complication of anticoagulant therapy: The intramural small bowel hematoma-A case report

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Intramural small bowel hematoma is a haemorrhagic complication of anticoagulant therapy.

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Abdominal complaints and elevated INR value should prompt suspicion.

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CT scan is the preferred imaging method.

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Immediate suspension of anticoagulant drugs and antidote administration is required.

Introduction

Intramural small bowel hematoma is a rare, and often overlooked consequence of anticoagulant therapy. In this report we present such a case in order to bring forth awareness to this entity, and its management.

Presentation of case

We report a 81-year old male who presented with abdominal pain for 2 days. He had been under anticoagulant therapy with warfarin for 9 years, presenting with an elevated INR of 6,2. Intramural small bowel hematoma was confirmed with abdominal ultrasound and CT scan. The patient was treated conservatively with anticoagulant suspension and administration of antidote, and was subsequently discharged after 6 days.

Discussion

Abdominal complaints and an elevated INR value point to the possible diagnosis of intramural small bowel hematoma, however these abdominal symptoms can vary between a mild pain and an established acute abdomen. CT scan showing symmetric bowel thickening associated with some luminal narrowing confirms the diagnosis. In terms of management, there are not sufficient papers to support a standardized treatment; currently the most accepted approach seems to be conservative treatment after the exclusion of complications that would call for surgery.

Conclusion

Anticoagulant therapy is becoming a widespread prescription as the population ages, and intramural small bowel hematoma is one consequence in need of consideration

Rectal colonic mural hematoma following enema for constipation while on therapeutic anticoagulation

Causes of colonic and recto-sigmoid hematomas are multifactorial. Patients can present with a combination of dropping hemoglobin, bowel obstruction and perforation. Computed tomography imaging can provide clues to a diagnosis of intramural hematoma. We present a case of rectal hematoma and a review of current management literature. A 72-year-old male on therapeutic anticoagulation for a pulmonary embolism, was administered an enema resulting in severe abdominal pain unresponsive to blood transfusion. A sigmoid colectomy with end colostomy was performed. Although rare, colonic and recto-sigmoid hematomas should be considered as a possible diagnosis for adults with abdominal pain on anticoagulant therapy.

Colonic Perforation Secondary to Idiopathic Intramural Hemorrhage

Intramural colonic hemorrhage is rare and often secondary to trauma or anticoagulation therapy. Idiopathic intramural hemorrhages in the alimentary tract have rarely been reported. While several reports of spontaneous perforation of an intramural rectal hematoma have been published, no reports of spontaneous perforation in the ascending colon due to a hematoma have. We describe a patient with an ascending colonic perforation secondary to spontaneous intramural hemorrhage. The patient is a 35-year-old male, who presented with acute abdominal pain and no history of trauma. An abdominal computed tomography scan showed a high-density area around the ascending colon, and nonoperative management was instituted. On the eighth hospital day, the pain worsened, and abdominal computed tomography scan showed free air. An emergent right hemicolectomy was performed. Intramural hematoma and ischemia with perforation, with no obvious etiology, were found. The patient was discharged on the 14th postoperative day.

Computed Tomography and Magnetic Resonance Imaging Findings in a Case of Colonic Intramural Hematoma After Mild Blunt Abdominal Trauma

Intramural hematomas can occur along any part of the gastrointestinal tract, being more common in the duodenum, jejunum, and ileum. Intramural colonic hematomas are very rare, and their main causes include abdominal trauma, anticoagulation, and coagulopathies. We report on a 27-year-old man with right lower quadrant pain for 1 day after a mild blunt trauma sustained during a soccer match. Computed tomography and magnetic resonance imaging evaluation revealed an intramural hematoma of the right colon, subsequently confirmed and drained through laparoscopic surgery. Although computed tomography and magnetic resonance imaging findings in such a context are scarce in the radiological literature, imaging has an important role in the preoperative diagnosis and evaluation of the extent of bowel hematomas to assist in treatment planning.

A belly of blood: A case report describing surgical intervention in a gastric intramural haematoma precipitated by therapeutic endoscopy in an anticoagulated patient

Gastric intramural hematoma, "intramural dissection" or "false aneurysm", is a rare and dangerous condition which may be more broadly classified as a spectrum of acute gastric mucosal injury. It is postulated that disruption of the mucosa and blood vessels within the submucosal layer results in dissection of the muscularis propria from the mucosa, with eventual clot formation. While a majority of cases resolve with conservative management, we describe a successfully managed case requiring surgical intervention. Progression of the haematoma was documented both endoscopically and surgically in an elderly anticoagulated patient who suffered a complication of therapeutic endoscopic intervention. A review of the literature is presented.

Postoperative Sigmoid Apoplexy: A Rare Entity in Pediatric Gastroenterology

An 11-year-old boy underwent ligation of sac for left congenital hydrocele. In the immediate postoperative period, he developed bleeding per rectum and obstructive features. Intramural hematoma of sigmoid colon was detected in diagnostic laparoscopy and confirmed by laparotomy. Sigmoidectomy with colorectal anastomosis was done. Postoperative period was uneventful.

How to cite this article: Jagannathan M, Krishnamurthy G. Postoperative Sigmoid Apoplexy: A Rare Entity in Pediatric Gastroenterology. Euroasian J Hepato-Gastroenterol 2014;4(2):110-112.

A curious case of spontaneous duodenal haematoma presenting a diagnostic challenge

Duodenal haematomas are uncommon. They are usually diagnosed on CT of the abdomen. The established treatment strategies are conservative management, surgical evacuation and percutaneous drainage. We present a case of spontaneous duodenal haematoma in a patient with no risk factors posing as a diagnostic challenge due to atypical CT findings. This case also illustrates the utility of ultrasound-guided needle aspiration as a practical treatment option for such haematomas.

Supportive management resolved a colonic intramural hematoma in an anticoagulant user

Intramural hematomas of the colon are rare. Intramural hematomas of the gastrointestinal tract often result from blunt trauma, although they may also occur spontaneously in patients taking anticoagulants or those with blood dyscrasia. Affected patients present with abdominal pain and lower gastrointestinal bleeding, as well as occasional signs of intestinal obstruction. The diagnosis is made using colonoscopy and abdominal CT. Resection of the involved bowel segment is accepted as the standard therapy; however, experience with conservative treatment has also been reported. We herein report the case of a 62-year-old woman taking warfarin who was diagnosed with a colonic intramural hematoma and completely recovered with conservative management.

Spontaneous perforation of an intramural rectal hematoma: Report of a case

Spontaneous hematomas are rare and most occur secondary to hematologic disorders or during anticoagulant therapy. Most spontaneous hematomas occur above the sigmoid colon, and rarely in the rectum. Herein we present the case of a patient with a spontaneous perforating hematoma of the rectum who presented with severe abdominal pain after a bloody stool. The hemoglobin level decreased by 33 g/L within 20 h. An abdominal sonogram showed a hydrops in the lower abdomen with a maximum depth of 7.0 cm. A hematoma, 8 cm × 6 cm × 5 cm in size, was noted intra-operatively in the rectosigmoid junction, with a 1.5-cm perforation in the hematoma and active hemorrhage. Thus, a partial rectectomy and sigmoidostomy were performed. Three months later, a second operative procedure to re-establish intestinal continuity was performed. The patient is in good condition 12 mo after the last surgery. In addition to this case, the causes of spontaneous perforating hematomas and the treatment are discussed.

[A case of intramural duodenal hematoma accompanied by acute pancreatitis following endoscopic hemostasis for duodenal ulcer bleeding]

Intramural duodenal hematoma is an uncommon condition, which usually develops after blunt abdominal trauma. It is also reported as a complication of anticoagulant therapy, blood dyscrasia, pancreatic disease, and diagnostic and therapeutic endoscopy. The typical clinical pictures of intramural duodenal hematoma consist of upper abdominal pain, vomiting, fever, and hematochezia, and it is rarely accompanied by intestinal obstruction, peritonitis, and pancreatitis as its complication. We report a case of intramural duodenal hematoma extended to peritoneal cavity, and accompanied by acute pancreatitis following therapeutic endoscopy for duodenal ulcer bleeding in a 32-year-old man who was on maintenance of anti-coagulation therapy after valvular heart surgery.

Gastric intramural hematoma: a case report and literature review

Intramural hematoma of the gastrointestinal tract is an uncommon occurrence, with the majority being localized to the esophagus or duodenum. Hematoma of the gastric wall is very rare, and has been described most commonly in association with coagulopathy, peptic ulcer disease, trauma, and amyloid-associated microaneurysms. A case of massive gastric intramural hematoma, secondary to anticoagulation therapy, and a gastric ulcer that was successfully managed with conservative therapy, is presented. A literature review of previously reported cases of gastric hematoma is also provided.

Bowel obstruction caused by an intramural duodenal hematoma: a case report of endoscopic incision and drainage

Complications associated with an intramural hematoma of the bowel, is a relatively unusual condition. Most intramural hematomas resolve spontaneously with conservative treatment and the patient prognosis is good. However, if the symptoms are not resolved or the condition persists, surgical intervention may be necessary. Here we describe internal incision and drainage by endoscopy for the treatment of an intramural hematoma of the duodenum. A 63-yr-old woman was admitted to the hospital with hematemesis. The esophagogastroduodenoscopy (EGD) showed active ulcer bleeding at the distal portion of duodenal bulb. A total of 10 mL of 0.2% epinephrine and 2 mL of fibrin glue were injected locally. The patient developed diffuse abdominal pain and projectile vomiting three days after the endoscopic treatment. An abdominal computed tomography revealed a very large hematoma at the lateral duodenal wall, approximately 10 x 5 cm in diameter. Follow-up EGD was performed showing complete luminal obstruction at the second portion of the duodenum caused by an intramural hematoma. The patient's condition was not improved with conservative treatment. Therefore, 21 days after admission, endoscopic treatment of the hematoma was attempted. Puncture and incision were performed with an electrical needle knife. Two days after the procedure, the patient was tolerating a soft diet without complaints of abdominal pain or vomiting. The hematoma resolved completely on the follow-up studies.

Obstructive rectal intramural hematoma caused by a foreign body

Intramural hematoma of the alimentary tract is a rare condition, which usually results from blunt injury. It can spontaneously occur in patients with coagulopathy or on anticoagulants. Although it may be seen anywhere in the alimentary tract, duodenum is the most common site of the intestinal intramural hematomas. Intramural hematoma caused by a foreign body is rarely seen. Patients with intramural hematoma are usually encountered with obstructive symptoms after an isolated injury. Intramural hematomas are often self-limited at the site of occurrence and can be managed conservatively. They rarely cause progressive obstruction and need surgical drainage. In this article, we report a 51-year-old male patient with foreign body used for masturbation causing rectal intramural hematoma and perforation at the rectosigmoid junction. Because of the intestinal perforation, the patient was managed surgically. In the diagnosis of intramural hematoma of the alimentary tract, beside the clinical history and physical examination, the findings at imaging modalities such as conventional radiography, ultrasonography, and computed tomography are often useful. Patients with rectal intramural hematoma usually do not give diagnostic clues to the physicians in the clinical history. Therefore, radiologists must be familiar with the imaging findings. In this article, we aimed to present a patient with rectal intramural hematoma caused by foreign body and obliterating the rectal lumen.

Intramural Hematoma of the Cecum as the Lead Point of Intussusception in an Elderly Patient with Hemophilia A: Report of a Case

Hemophilia A is a congenital bleeding disorder characterized by a deficiency of coagulation factor VIII. Intramural hematoma of the colon is a very rare complication of this disease. We report a case of intramural hematoma of the cecum serving as the lead point of intussusception in a 65-year-old man with hemophilia A. The patient presented with right-sided abdominal pain and bloody stool. Palpation of his abdomen revealed a fist-sized mass. Abdominal computed tomography (CT) showed a circular mass with concentric rings, consistent with an intussuscepted intestine. Because his activated partial thromboplastin time (APTT) was prolonged, we gave him a continuous infusion of factor VIII during and after surgery. Laparotomy revealed an irreducible colo-colic intussusception and we identified a cecal hematoma as the lead point. After an unsuccessful attempt at Hutchinson's maneuver, we performed right colectomy. We report this case to illustrate the necessity of monitoring APTT in patients with hemophilia A who undergo surgery.

Hematoma intramural duodenal como complicação de terapia anticoagulante com Warfarin: relato de caso e revisão da literatura

Relatamos o caso de uma paciente em terapia anticoagulante oral com Warfarin, apresentando obstrução intestinal aguda. A tomografia computadorizada revelou hematoma intramural duodenal. O tratamento baseou-se na correção das provas de coagulação e medidas expectantes. Este caso ilustra o valor da tomografia computadorizada e da abordagem conservadora nos pacientes em terapia anticoagulante com obstrução aguda do intestino delgado.

Occlusive intraluminal hematoma

We report an unusual case of a 10-month-old girl who developed partial small-bowel obstruction caused by an intraluminal hematoma within the terminal ileum. Passage of bright red blood through her rectum prompted radiologic evaluation with computed tomography, barium enema, and ultrasound. These revealed an avascular right lower-quadrant mass within the lumen of the terminal ileum. An exploratory laparotomy was performed, and a large obstructing hematoma was removed.

Anticoagulant-induced intramural intestinal hematoma

Intramural hematoma of the intestine is a rare complication of anticoagulant therapy. We evaluated 7 nontrauma patients with intramural hematoma of the intestine diagnosed at our institution between May 1998 and June 2001. All of the patients were receiving long-term anticoagulant therapy for previous diseases. All 7 patients had abdominal pain, 6 had additional symptoms of nausea and vomiting, and 4 had melanotic stools at admission. Six of the patients had abnormal coagulation parameters. Both abdominal ultrasonography (US) and computerized tomography (CT) showed the exact pathology in all patients. Five of the 7 patients were treated, nonoperatively, and the other patients underwent surgery. All of the patients were followed with abdominal US and CT (mean 12 = months), with complete resolution of their intramural hematomas. Abdominal US and CT evaluation performed together will help the accuracy of diagnosis of intramural hematoma, but nonoperative therapy is the treatment of choice, with surgery indicated if generalized peritonitis or intestinal obstruction develops.

Spontaneous intramural small-bowel hematoma: imaging findings and outcome

OBJECTIVE

Our aim was to review the imaging findings and outcomes of patients with nontraumatic spontaneous intramural small-bowel hematoma.

MATERIALS AND METHODS

We retrospectively reviewed the records and radiologic studies of 13 patients with known intramural small-bowel hemorrhage.

RESULTS

The mean age at presentation was 64 years. Sixty-two percent of patients had warfarin toxicity. The diagnosis was evident on CT performed in all patients. Small-bowel obstruction was present in 85% of patients, and biliary obstruction was present in 8%. A single hematoma was present in 85% of patients, and multiple hematomas were present in 15%. The jejunum was the most common site of the hematoma (69%), followed by the ileum (38%) and duodenum (23%). The hematoma extended into the cecum in 15% of patients. The estimated average length of the hematoma was 23 cm, and the shortest segment was 8 cm. Resolution of the hematoma was seen on CT as early as 1 week after onset. Eleven patients (85%) with non-extensive hematomas were dismissed from the hospital without any short- or long-term complications (mean follow-up, 35 months). Two patients with extensive hematomas involving more than half the length of the small intestine died.

CONCLUSION

Spontaneous intramural small-bowel hematoma is rare. It occurs in patients who receive excessive anticoagulation with warfarin or who have some other risk factor for bleeding. CT characteristics include circumferential wall thickening, intramural hyperdensity, luminal narrowing, and intestinal obstruction. Early diagnosis is crucial because most patients are treated nonoperatively with a good outcome.

Spontaneous perforating hematoma of the rectum. Report of a case

Intramural hematomas of the intestine most often occur in the setting of blunt abdominal trauma. However, spontaneous hematomas can occur secondary to either hematologic disorders, or use of anticoagulant therapy. There has been no clearly documented report of a spontaneous rectal hematoma. We describe the novel treatment of a patient with a spontaneous intramural hematoma of the rectum which presented as an abdominal catastrophe.

A case of traumatic intramural hematoma of the duodenum effectively treated with ultrasonically guided aspiration drainage and endoscopic balloon catheter dilation

A 52-year-old man was admitted on February 15, 1990, with hiccups and vomiting. He had been well until 13 days before admission when he stumbled and fell when intoxicated, striking his abdomen. A diagnosis of intramural hematoma was made with computerized tomography and sonography of the abdomen after admission, revealing a mass that was intimately related to the duodenum. Treatment of the intramural duodenal hematoma is controversial. However, this case illustrates the ideal situation where conservative management could be applied with total parenteral nutrition, percutaneous aspiration drainage, and endoscopic balloon catheter dilatation of the narrowed lumen of the duodenum. The patient's subsequent course supports the concept of planned conservative management.

Duodenal hematoma: CT demonstration of the ring sign

This case illustrates the computed tomographic (CT) and sonographic features of duodenal hematoma. In addition, the CT scans demonstrate the ring sign, a characteristic feature noted previously only by magnetic resonance imaging.