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Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00842-2
10.1016/j.radcr.2024.08.062
Case Report
Parietal hematoma of the small bowel due to anticoagulant overdose: A case report
Faye Ibrahima fayebarham1992@gmail.com
a⁎
Niang Fallou Galas a
Diallo Adja Coumba b
Ndong Abdourahmane b
Diop Ndeye Rokheya c
Beye Serigne Mor c
Sarr Ndiame b
Konaté Ibrahima b
Diop Abdoulaye Ndoye a
a Radiology Department, Regional Hospital Center of Saint Louis, Saint Louis, Senegal
b General Surgery Department, Regional Hospital Center of Saint Louis, Saint Louis, Senegal
c Cardiology Department, Regional Hospital Center of Saint Louis, Saint Louis, Senegal
⁎ Corresponding author. fayebarham1992@gmail.com
12 9 2024
12 2024
12 9 2024
19 12 57755778
1 4 2024
10 8 2024
12 8 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Anticoagulant-induced spontaneous small bowel hematoma is a rare cause of acute mechanical bowel obstruction. We report the case of a 77-year-old patient with complete arrhythmia due to atrial fibrillation under acenocoumarol 4mg daily who was seen for right iliac fossa pain. The laboratory tests showed a prothrombin rate (PT) of 12%, an International Normalized Ratio (INR) of 6, and an aPTT (activated partial thromboplastin time) of 43 seconds. Abdominopelvic ultrasound showed an echogenic pelvic effusion. The diagnosis of the small hematoma was made by abdominopelvic CT scan, which showed a thickening of the small bowel wall reducing its caliber associated with a parietal hematoma . The evolution was unremarkable under supplementation therapy vitamin K.

Keywords

Hematoma
Anticoagulant
Small bowel
CT scan
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pmcIntroduction

Hemorrhagic events caused by vitamin K antagonists (VKAs) are common in practice. They are the leading cause of iatrogenic accidents, accounting for 13% of hospitalizations for adverse drug effects, with 17,000 hospitalizations per year [1]. The incidence of anticoagulant-induced gastrointestinal bleeding is approximately 3% to 4% [2]. Indeed, these complications can lead to intestinal obstruction.

We report a case of a patient who experienced small bowel obstruction due to a hematoma following the use of VKAs.

Observation

The patient was a 77-year-old woman without a history of trauma with complete arrhythmia due to atrial fibrillation on a daily dose of 4 mg of acenocoumarol, who presented with abdominal pain predominantly in the right iliac fossa during follow-up.

On physical examination, the patient's general condition was preserved with clear mucous membranes and supple calves without lower limb edema. Blood pressure was at 100/80 mm Hg, temperature at 37.3°C, and respiratory rate at 26 cycles/min. Abdominal examination revealed tenderness on palpation of the right iliac fossa. There were no signs of peritoneal irritation on rectal examination.

Laboratory tests showed a prothrombin rate of 12% (>70%); International Normalized Ratio (INR) of 6(2-3 patient on anticoagulant); activated partial thromboplastin time (aPTT) of 43 seconds (20-40 s). Full blood count revealed hemoglobin levels at 10 g/dL (>12g/dL), hematocrit at 29.5% (37-48%), white blood cells at 8420/µL (4000-11000 /µL), platelets at 366,000/ mm3 (150,000-300,000 mm3), and C-reactive protein at 192 mg/L (<6 mg/L). Given the abdominal pain and an inflammatory syndrome, an abdominopelvic ultrasound was performed to rule out appendicitis, which revealed peritoneal fluid and necessitated an abdominal CT scan. The CT scan showed a thickening of the small bowel wall reducing its caliber associated with a parietal hematoma (Fig. 1).Fig. 1 Axial (A), coronal (B), and sagittal (C) slices of the abdominal CT scan showing a nonenhancing thickening of the small bowel wall (orange arrow).

Fig 1

After 1 week of hospitalization with cessation of anticoagulant therapy, treatment with vitamin K1 and transfusion of 2 units of fresh frozen plasma improved the patient's clinical condition. During the follow-up prothrombin time was at 59%, INR at 1.47, and aPTT at 26.7 seconds. A follow-up abdominal CT scan performed 15 days later was normal (Fig. 2), motivating hospital discharge. The patient was transferred to the cardiology unit for follow-up.Fig. 2 Axial slice of the control CT scan showing resorption of the parietal digestive hematoma (red arrow).

Fig 2

Discussion

Parietal hematoma of the small bowel is a rare complication of anticoagulant therapy [3]. First described by McLouchlan in 1838 on an autopsy specimen [4], its incidence is estimated at 1/2500 [5]. Pathophysiologically, it manifests as segmental haematoma infiltration of the intestine, potentially causing intestinal lumen obliteration with hemoperitoneum and possible gastrointestinal bleeding. Abdominal pain in the context of anticoagulant use is the main symptom [6,7]. Vomiting and intestinal transit d disorders suggestive of an occlusive syndrome may be noted, as well as hemorrhagic syndrome [8], such as hematuria presented by our patient.

Coagulation tests revealed an elevated International Normalized Ratio (INR) [8], which was 6 in our patient, correlating with bleeding. However, a normal INR does not prevent the occurrence of hematoma; the risk of bleeding is related to the intensity of anticoagulation [9].

Several factors are implicated in the occurrence of an overdose: age over 65, female gender, a history of hemorrhage under VKAs (vitamin K antagonists), poor treatment follow-up, and lack of monitoring, arterial hypertension, diabetes, liver failure which potentiates the response to VKA due to a defect in coagulation factor synthesis. The co-prescription of drugs that potentiate the effect of VKA is also a predictive factor of bleeding. It is important to emphasize on the use of certain medications because of their common prescription: these include nonsteroidal anti-inflammatory drugs, antibiotics of which almost all classes have a potentiating effect on VKA treatment, proton pump inhibitors (such as Omeprazole), and antiplatelet agents [10].

Diagnosis of small bowel hematoma can be suspected on ultrasound in the presence of digestive wall thickening and hemoperitoneum, but the CT Scan remains the approach of choice [11].

In our patient, the ultrasound was inconclusive, and the diagnosis was made by CT Scan which showed spontaneous hyperdensity of the jejunal wall without enhancement after contrast injection. This thickening reduced the intestinal lumen and caused upstream obstruction No complications were noted in our patient.

Spontaneous intramural (nontraumatic) hematomas of the digestive tract most commonly affect the jejunum, ileum, duodenum (especially D2 and D3), and less frequently the colon and esophagus [8,12].

Anatomically, the susceptibility of the duodenum to be the site of an intramural hematoma is probably explained by its rich submucosal vasculature [13]. Additionally, the duodenum does not have a complete circumferential serosal layer, which prevents the containment of an intramural hemorrhage, allowing the hematoma to easily extend circumferentially and longitudinally, sometimes to a very significant extent [12].

The prognosis is often cogent under medical treatment marked by clinical improvement, normalization of INR, and hematoma resorption occurring between 10 days and 2 months [14]. Indeed, our patient's CT Scan follow-up, performed 15 days after treatment, was normal.

The course may be complicated, requiring surgical management to evacuate the hematoma [6,8]. Prognosis depends on comorbidities and delayed diagnosis [8]. However, our patient had an unremarkable outcome.

Conclusion

VKA-induced spontaneous small bowel hematoma is a rare clinical condition. It should be suspected in cases of abdominal pain in patients on receiving anticoagulant therapy. While ultrasound may suggest the diagnosis, CT scan remains the gold standard.

The prognosis is often cogent under medical treatment, but surgery may be necessary in cases of complication.

Patient consent

Written informed consent for the publication of this case report was obtained from the patient.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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