Spontaneous intramural small-bowel hematoma: imaging findings and outcome

Our aim was to review the imaging findings and outcomes of patients with nontraumatic spontaneous intramural small-bowel hematoma.

We retrospectively reviewed the records and radiologic studies of 13 patients with known intramural small-bowel hemorrhage.

The mean age at presentation was 64 years. Sixty-two percent of patients had warfarin toxicity. The diagnosis was evident on CT performed in all patients. Small-bowel obstruction was present in 85% of patients, and biliary obstruction was present in 8%. A single hematoma was present in 85% of patients, and multiple hematomas were present in 15%. The jejunum was the most common site of the hematoma (69%), followed by the ileum (38%) and duodenum (23%). The hematoma extended into the cecum in 15% of patients. The estimated average length of the hematoma was 23 cm, and the shortest segment was 8 cm. Resolution of the hematoma was seen on CT as early as 1 week after onset. Eleven patients (85%) with non-extensive hematomas were dismissed from the hospital without any short- or long-term complications (mean follow-up, 35 months). Two patients with extensive hematomas involving more than half the length of the small intestine died.

Spontaneous intramural small-bowel hematoma is rare. It occurs in patients who receive excessive anticoagulation with warfarin or who have some other risk factor for bleeding. CT characteristics include circumferential wall thickening, intramural hyperdensity, luminal narrowing, and intestinal obstruction. Early diagnosis is crucial because most patients are treated nonoperatively with a good outcome.