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.