Small bowel obstruction caused by intramural hemorrhage secondary to anticoagulant therapy

Intramural hemorrhage as a cause for small bowel obstruction is extremely rare. We presented an unusual case report of small bowel obstruction caused by intramural jejunal hemorrhage secondary to anticoagulant therapy. An 85-year-old male patient with atrial fibrillation on long-term warfarin presented with nausea and vomiting for 2 days, accompanied with no bowel movement since the onset. Physical exam was unremarkable except soft abdomen with distension but no tenderness, hyperactive bowel sounds and positive fecal occult blood test. Investigations showed anemia with hemoglobin/ hematocrit of 10 (g/dl) / 30%, prothrombin time with an International Normalized Ratio (INR) of 9.58. Abdominal x-ray showed air fluid levels suggestive of small bowel obstruction. Contrast-enhanced abdominal computerized tomography showed circumferential wall thickening, luminal narrowing and partial small bowel obstruction secondary to intramural jejunal hemorrhage. Patient recovered completely 48 hours after medical treatment (nothing per oral, intravenous fluids, nasal gastric tube, Vitamin K, frozen fresh plasma and packed red blood cell transfusion). Spontaneous intramural small-bowel hematoma is rare and occurs in patients who receive excessive anticoagulation with warfarin or who have some other risk factors for bleeding. Intramural hematoma most commonly involves the jejunum, followed by the ileum and the duodenum. The spectrum of presentation is wide, from abdominal pain, emesis to gastrointestinal tract hemorrhage. Abdominal CT is the key for diagnosis, with characteristics including circumferential wall thickening, intramural hyperdensity, luminal narrowing, and intestinal obstruction. Early diagnosis is crucial because most patients are treated nonoperatively with a good outcome.