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.
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.