An 85-year old lady presented as an emergency with sudden onset of severe left sided abdominal pain and vomiting for two days. This was associated with constipation for 3 days. She had a past medical history of atrial fibrillation, angina, and pulmonary embolism for which she was anticoagulated with warfarin. There was no history of trauma.\nOn examination she was haemodynamically stable. Her abdomen was generally tender, maximal tenderness being in the left hypochondrium and left lumbar region, associated with some guarding and rigidity. Bowel sounds were present and the rectal examination was unremarkable.\nThe blood tests revealed normal haemoglobin, marginally raised white cell count (12.5) and C- reactive protein (25.3), and a grossly deranged International Normalised Ratio (INR) of 8.9. Her renal and liver functions function tests were within normal limits. An erect Chest X-ray and supine abdominal films were both unremarkable. Computed Tomography (CT) Scan showed a long abnormal loop of thick walled jejunum with a small amount of free fluid in the intraperitoneal cavity (Figure and ).\nA diagnosis of spontaneous intramural haematoma of the jejunum was made. She was treated conservatively with nil by mouth, intravenous fluids, and nasogastric suction. Fresh frozen plasma and vitamin K were given to normalise her clotting parameters. Her symptoms subsided gradually over the next couple of days and she was gradually started on fluid and diet. The clotting parameters normalized and she was discharged home on normal diet six days later.
A 61 year old male with history significant for right lower extremity deep venous thrombosis (DVT); on warfarin 7.5 mg, hypertension, diabetes mellitus, asthma, and chronic kidney disease presented to the emergency department with 3 day history of generalized abdominal pain associated with multiple episodes of nausea, vomiting and obstipation. Patient was awake, alert and oriented. Blood pressure was elevated, rest of vitals were benign. On physical examination, patient had distended abdomen with mild generalized tenderness, no signs of peritonitis. Remainder of his exam was un-remarkable. Labs were significant for INR; >6 and PTT; 91.9. CT abdomen was obtained that showed high grade small bowel obstruction (, ). Patient was admitted under surgical team and initially managed by bowel rest with nil per os(NPO), nasogastric tube to suction showed 1.3 L of bilious fluid, and foley catheter was inserted. Patient was given 6 FFPs to resuscitate in the emergency room. Repeated INR obtained and was found to have 2.16. At this time, patient was taken to the operating room for diagnostic laparoscopy. Intra- operatively, patient was found to have dilated small bowel along with a segment of bowel with intramural and mesenteric hematoma involving 30 cm of the jejunum (, ). Ischemic small bowel with intramural hematoma was resected and anastomosed primarily. Post-operative management in intensive care unit (ICU) was uneventful and patient was discharged home on post op day 5 without any further complications.