Spontaneous intramural small-bowel hematoma due to a rare complication of warfarin therapy: Report of two cases

Abstract

Spontaneous intramural small-bowel hematoma secondary to warfarin therapy has been reported in the literature, but this complication of anticoagulant therapy is still considered rare. Here we report two cases of spontaneous nontraumatic jejunal intramural hematoma treated in our institution. After emergent admission for acute abdomen, both cases were found to have a history of warfarin therapy for atrial fibrillation. Prothrombin time, activated partial thromboplastin time, and international normalized ratio were elevated in both cases. For Case 1, abdominal computed tomography revealed segmental mural thickening with precontrast hyperdensity and perienteric haziness affecting the distal jejunum. The patient underwent emergent laparotomy under the impression of mesentery occlusion with impending bowel ischemia due to her history of atrial fibrillation. Abdominal computed tomography for Case 2 revealed jejunal intramural hematoma and bloody ascites. The patient received conservative therapy with nil by mouth, fresh frozen plasma transfusion, and vitamin K1 supplementation, and no surgical intervention was done based on experience gained with the first case. Although a few other recent cases have been reported, the differences in our two cases were especially helpful in demonstrating that surgery can be avoided. We suggest that a history of anticoagulant use with prolonged international normalized ratio values in patients presenting with abdominal pain should alert physicians to consider spontaneous intramural small-bowel hematoma secondary to warfarin therapy. Recognizing this syndrome is important in order to avoid unnecessary surgery because excellent outcomes can be achieved with conservative treatment.