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.
An 81-year-old woman was admitted to the Mazandaran Heart Center, Sari, Iran in February, 2018 with a 4-day history of nausea, vomiting, and abdominal pain. She had been taking Warfarin (5 mg orally once a day) and aspirin (80 mg/day) for 8 years after aortic valve replacement without close monitoring and had a history of hematochezia caused by Warfarin toxicity one year ago. Colicky pain, an increase in bowel sounds and periumbilical tenderness without distension was determined by physical examination. The primary laboratory findings revealed anemia (Hb: 9.8 g/dl; normal value: 11.5–13.5 g/dl) and elevated INR (6; therapeutic range: 2–3.5), liver function and biochemistry tests were within normal values. Normal left ventricular systolic function, LVEF of 55–60%, septal hypertrophy, normal functioning prosthetic valve, and dilatation of the ascending aorta were reported by echocardiography.\nDuring an abdominal and pelvic ultrasound, long mucosal thickening possibly through the ascending and sigmoid colon was observed, suggestive of intramural hematoma. The patient was placed on\nnil per os, received supportive care and two units of fresh frozen plasma. Due to normal cardiac evaluation and partial relief of symptoms on the second day of admission, the patient was referred to surgical consultation with the possible diagnosis of descending colon and sigmoid intramural hematoma. For re-administration of anticoagulants, heparin infusion (1000 units/hour) began with precise monitoring of prothrombin time.\nOn the fourth day, CT scan was performed with intravenous and oral contrast (\n) and intramural hematoma of ileum was diagnosed. During the CT, a radiologist noticed a mass on the left breast and a lymph node with a malignant feature on the left axilla. With the improvement of abdominal pain and vomiting (on the fourth day), oral feeding was resumed. After mammography and breast biopsy, pathological examination revealed invasive ductal cell carcinoma with lymphatic and perineural invasion. According to the immunohistochemistry staining, tumor cells were strongly ER positive, PR negative, 15% Ki67 positive and equivocal for HER2. The patient was referred to the oncology-hematology department to receive appropriate treatment.\nThe patient was discharged 10 days after admission and Warfarin therapy (5 mg/d) was resumed. The patient was visited 2 weeks later with good general health assessment. Letrozole (2.5 mg/day) was started because the patient refused chemotherapy and radiotherapy.