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.
The patient is a 52-year-old incarcerated male with a past medical history of diabetes mellitus, chronic pancreatitis, and remote history of open cholecystectomy who was transferred to the hospital for complaint of abdominal pain. He reported three days of worsening epigastric and periumbilical abdominal pain with associated nausea and obstipation. He also reported two days of hematuria without dysuria or frequency. Four days prior, he was awakened by another prisoner who was kicking him in the abdomen.\nOn presentation, he was tachycardic but normotensive. His abdomen was distended and diffusely tender. Initial lab work was notable for leukocytosis of 17 and significant coagulopathy with an unmeasurable international normalized ratio (INR), partial thromboplastin time (PTT) > 200, and prothrombin time (PT) > 120. Repeat labs confirmed the coagulopathy. He denied any ingestions or known exposures. He was given two units of fresh-frozen plasma (FFP) as well as vitamin K and his coagulopathy began to correct.\nA CT scan of the abdomen/pelvis revealed significant bowel dilatation with mural edema and thickened loops of jejunum (Figure ). There was fecalization of the proximal small bowel consistent with high-grade small bowel obstruction. Given his tachycardia, obstructive symptoms, diffuse abdominal pain and CT findings, there was concern for intestinal ischemia and the decision was made to perform an exploratory laparotomy. On inspection, the mid-small bowel was dilated with about 30 centimeters of thickened small bowel with circumferential hematoma. The entirety of the small bowel was examined and the point of obstruction appeared to be the extensive small bowel hematoma. This portion was resected and primarily anastomosed. The abdomen was closed and the patient was brought to the recovery room.\nHis post-operative labs were notable for a normalizing INR of 1.4 and PTT of 30. Given the unclear etiology for his extreme coagulopathy, Hematology was consulted. He had no family history of coagulopathies or hematologic disorders. He reported no history of bleeding symptoms prior to this episode. Coagulation studies were consistent with a deficiency of vitamin K dependent clotting factors that corrected with mixing studies. Differential diagnosis included common pathway factor deficiency, inhibitor exposure, or false result. Disseminated intravascular coagulation (DIC) and liver failure were ruled out. As his coagulopathy quickly corrected with FFP and vitamin K, the most likely etiology was exposure to overdose of a warfarin-based substance. He received additional vitamin K and recovery was otherwise unremarkable. Hematuria had resolved with correction of the coagulopathy. He was discharged on the seventh post-operative day to the prison infirmary. The final pathology was notable for portion of small intestine with transmural hemorrhage with clear resection margins.