intramural hematoma secondar”>Case Report

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American Journal of Emergency Medicine

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Small bowel intramural hematoma secondary to Abdominal massage

Abstract

Oral anticoagulant therapy with warfarin is commonly used to prevent thromboembolic event in patients at risk with atrial fibrillation [1]. Spontaneous intramural hematoma of Small intestine is rare complication of anticoagulant therapy and occurs in patient who receives excessive warfarin that may result in potentially serious complications. Small bowel intramural hematoma secondary to Warfarin therapy is a recognized complication [2]. In the present report, we report an unusual case of small bowel intramural hemorrhage secondary to anticoagulant therapy after abdominal massage. The emergency physicians should be aware that the potential spontaneous small bowel intramural hemorrhage in the patients has a high index of suspicion because most patients are treated nonoperatively with a good outcome.

A 68-year-old man with a 3-year history of atrial fibrillation and cerebrovascular disease, which had been treated with warfarin. The patient presented to the emergency department with a 2-day history of persistent abdominal pain and vomiting, accompanied with no bowel movement since the onset. He did not have a history of trauma. He experienced chronic constipation with abdominal massage 3 days before presentation. Physical examination was unremarkable except soft abdomen with distension and tenderness more marked in the lower quadrants. Bowel sounds were decreased. Digital examination produced blood-streaked stool. A complete blood cell count showed leukocyte count of 12000/mm³ with 88% segmented neutrophils, anemia with hemoglobin level of 10 mg/dL, C-reactive protein of 5 mg/L, glucose 158 mg/dL, serum urea nitrogen 42 mg/dL, serum creatinine 1.7 mg/dL, sodium 138 mEq/L, potassium

4.8 mEq/L, prothrombin time with an international normalized ratio of 4.25.

Abdominal x-ray showed air fluid levels suggestive of Small bowel obstruction. Contrast-enhanced computed tomographic scans showed segmental circumferential wall thickening, luminal narrowing, and partial small bowel obstruction secondary to intramural distal jejunum hematoma (Fig.). During admission, warfarin was discontinued, bowel rest, nasogastric decompression, hydration, vitamin K, frozen fresh plasma, packed red blood cell transfusion, and total parenteral nutrition were administered. The patient recovered uneventfully 3 days after conservative treatment. Small bowel intramural bleeding should usually be treated conservatively if the diagnosis is made by radiographic studies. Computed tomography is the best imaging technique of choice. Intramural hematoma most commonly involves the jejunum, fol- lowed by the ileum and the duodenum. typical findings on abdominal CT are helpful in establishing the diagnosis, with characteristics including short segmental circumferential wall thickening, intramural hyperdensity, luminal narrowing, and intestinal obstruction [3,4]. Intramural hemorrhage tends to involve a short segment of small

bowel and marked wall thickening, whereas a greater length and mild wall thickening of involvement are present in patients with intestinal ischemia [3]. The most common presenting symptoms are abdominal pain, emesis, abdominal distension with guarding and rebound tenderness, and gastrointestinal bleeding [1]. Early diagnosis is crucial because most patients are treated with medical treatment and had a good outcome.

Anticoagulants have been used increasingly in the treatment of myocardial infarction, cerebral arteriosclerosis, and pulmonary embolism. Although intramural small bowel hemorrhage is rare, its incidence is expected to increase as a result of an aging population requiring more chronic long-term anticoagulation therapy. Constipa- tion is a common problem among Elderly people. The usual treatment for chronic constipation is laxative therapy and physiotherapy. Physiotherapy intervention may consist of abdominal massage and exercise that may improve normal bowel activity and increase function [5]. Patients with suspected abdominal obstruction, received recent abdominal radiotherapy and surgery, intestine inflammation disease, irritable bowel syndrome, and pregnancy are contraindica- tions for referral for abdominal massage [6]. Intramural hematoma of the duodenum is uncommon conditions, which develops after abdominal massage. Small bowel intramural hematoma may be diagnosed as a complication of the abdominal massage in a patient with a bleeding tendency, such as anticoagulant therapy. To our knowledge, we describe the first reported case of intraluminal hematoma as a rare cause of abdominal massage during warfarin therapy. The emergency physicians should be aware of such

Fig. contrast-enhanced CT scan shows cross-sectional image of thickened wall of jejunum due to intramural hematoma (arrows).

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complication after abdominal massage in patients with a history of anticoagulants administration even if international normalized ratio is in the therapeutic range.

Hsin-Ling Chen MD

Emergency Department Shin Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan

Chin-Chu Wu MD

Dept. of Medical Imaging Shin Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan

Aming Chor-Ming Lin MS, MD

Emergency Department Shin Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan Department of Intensive Care Unit

Shin Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan

School of Medicine Fu-Jen Catholic University New Taipei City, Taiwan

E-mail addresses: [email protected]

[email protected] http://dx.doi.org/10.1016/j.ajem.2012.11.020

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