MED-21. Spontaneous intramural small bowel hemorrhage: a rare complication of anti-coagulation.
Spontaneous intramural small bowel hemorrhage is a rare
complication of anticoagulant therapy, occurring with an incidence of 1
in 2500 patients on oral warfarin. The diagnosis often may not be
suspected clinically, but is usually found on CT scan of patients
referred for suspicion of other intra-abdominal pathology. We discuss a
case of intramural small bowel hemorrhage in a patient supratherapeutic
on warfarin therapy. Appropriate management of supratherapeutic
coagulation times is also discussed. A 78-year-old male with a history
of coronary artery disease, diverticulosis and recent afib/flutter
presented with progressively worsening LLQ abdominal pain of a 2-day
duration. The patient described the pain as aching in character without
radiation. The patient also reported constipation and nausea for 3
days' duration. Of note, the patient was recently discharged from
the hospital a month ago on oral warfarin with a new diagnosis of
afib/flutter. Abdominal exam was revealing for diffuse discomfort but
notable tenderness in the LLQ. No mass was palpable at that time, and no
peritoneal signs were appreciated. The patient's while blood cell
count was 11,000/[mm.sup.3] with hemoglobin of 15.7gm/dL. Liver function
tests were unremarkable, however the patient had a significantly
elevated prothrombin time of >120 seconds. Acute abdominal series was
negative for free air or obstruction. Diverticulitis was suspected,
warfarin was held, and the patient was placed on broad-spectrum
antibiotics for diverticulitis therapy. CT scan of the abdomen and
pelvis revealed a thickened segment of small bowel, consistent with
intramural small bowel hematoma. The patient led a complicated course
with hemorrhage from the intramural hematoma into the peritoneal cavity
but was ultimately discharged in stable condition off warfarin.
Suspicion of intestinal intramural hemorrhage should be considered in
any patient on anti-coagulant therapy and complaining of abdominal pain.
With aggressive medical treatment alone, morbidity in these patients can
be decreased and preclude the need for surgical intervention.
Andrew I. Rackoff, MD, and Shoban Dave, MD. Department of Internal
Medicine, Medical University of South Carolina, Charleston, SC.