Sistema gastrointestinal y digestivo

Abstracto

A Rare Cause of Intestinal Volvulus: Spontaneous Intramural Hematoma of Small Intestine

Y El Gamrani, Z Chahbi, H Qacif, S Kaddouri, A Ait Badi, M Zyani

Introduction: Anticoagulation therapy is widely used for curative and prophylactic purposes. The most serious complication is bleeding, which presents as an intramural hematoma of the small intestine; however, it is uncommon, seen in 1 in 2,500 patients. We report an unusual case of a warfarin overdose that resulted in spontaneous intramural hematoma of the small intestine with intestinal volvulus.

Observation: A 60-year-old patient was admitted to the emergency department with diffuse abdominal pain and anuria that had started several hours earlier. The patient had a long history of complicated diabetes, marked by moderate chronic renal failure as well as arterial hypertension and atrial fibrillation, which was managed with the oral anticoagulant acenocoumarol. Respiratory and cardiovascular exams revealed no abnormality except for an irregular rhythm in cardiac auscultation. His abdomen was mildly distended and there was tenderness with Blumberg’s sign in the periumbilical region, which was associated with signs of peritoneal irritation. Laboratory tests showed incoagulable plasma, an inflammatory syndrome, and renal failure. The Computed tomography (CT) scan without intravenous injection revealed a spontaneous intramural hematoma of the small intestine with intestinal volvulus; moderate hemoperitoneum was also documented. Initial patient management consisted of the cessation of oral anticoagulation therapy, gentle gastric aspiration, correction of the coagulopathy with fresh frozen plasma, and the administration of parenteral Vitamin K. The patient’s condition began to decline, marked by a worsening of clinical and laboratory parameters, and the patient ultimately died from acute cardio-circulatory failure while on ventricular fibrillation.

Conclusion: Spontaneous small intestine hematoma is an uncommon clinical complication, but it should be taken into consideration for any patient on long-term anticoagulation therapy who presents with acute abdomen. Abdominal CT is the key for diagnosis. Early diagnosis is crucial because most patients can be treated nonoperatively with a good outcome.