日外科系連会誌 43（４）：611–615，2018Case Report
Spontaneous Intramural Hematoma of the Jejunum Inducedby Anticoagulant Therapy
Takashi Hirosawa, Katsuyoshi Kudoh, Takeshi Aoki, Shinobu Ohnuma,
Naoki Tanaka, Hiroaki Musha, Fuyuhiko Motoi, Takashi Kamei,
Takeshi Naitoh and Michiaki Unno
Department of Surgery, Tohoku University Graduate School of Medicine

Abstract
A spontaneous, intramural, small-bowel hematoma
requiring a surgery is a rare complication of anticoagulant therapy. We present a case of an 82-yearold man who developed abdominal pain in the setting of abnormal coagulation function related towarfarin therapy used as chronic prophylaxis
against recurrent pulmonary embolism. Computed
tomography (CT) showed wall thickening and luminal narrowing of the jejunum. Dilation of the small
bowel proximal to the thickening was also present,indicative of small bowel obstruction. Initially, thepatient was treated conservatively, but he later required laparotomy due to worsening of his generalcondition. A 50cm jejunal segment was resected inorder to relieve the intestinal obstruction and to arrest the bleeding. For intramural, small-bowel hematoma, conservative medical management shouldbe the first treatment of choice, but surgical intervention may be indicated if conservative treatment
is not successful.
Key words: Anticoagulant, Intramural hematoma,
Surgical treatment
Introduction
Oral anticoagulants are widely prescribed in many
conditions as prophylactic and therapeutic agents.
Warfarin is the most frequently used of these drugs,
Received: August 17, 2017/ Accepted: December 6, 2017
Correspondence to: Kudoh Katsuyoshi
Department of Surgery, Tohoku University Graduate
School of Medicine
1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japanand its most serious complication is excessive anticoagulation, with bleeding; such spontaneous bleeding occurs in about 7.6 per 100 patient-years andprimarily in the digestive tract1）.
In Switzerland, incidence of small bowel hematomas was reported to be 1: 2,500 patients on anticoagulation per year2）. However, there have not been
many cases that needed surgical treatment 3）.
We present a case of spontaneous intramural hematoma of the jejunum which was presumed to haveoccurred due to drug interaction during warfarinanti-coagulant therapy.

Case Report
A man in his 80ʼs with a history several years previously of pulmonary embolism and chronic obstructive pulmonary disease was admitted for radiation
therapy for lung carcinoma. His medications included allopurinol 100mg/day, warfarin 3mg/day, aspirin
100mg/day, candesartan cilexetil 8mg/day and clarithromycin 200mg/day. Three days after admission,
the patient developed abdominal pain and vomiting.
Plain and contrast-enhanced computed tomography(CT) demonstrated circumferential wall thickening,
luminal narrowing, and intramural hyperdensity of
the jejunum with hyperdense ascites in Douglasʼ
pouch (Fig. 1 ). Laboratory investigations showed ahemoglobin level of 11.5g/dl, a platelet count of 196
× 10 3 /µl, a markedly prolonged prothrombin timeinternational normalized ratio (PT-INR) >7.0 and aprolonged activated partial thromboplastin time of
72.4s. Warfarin and aspirin were stopped and replaced with low molecular weight heparin (dalteparin sodium). The patient was treated conservatively
with bowel rest, intravenous fluid hydration and in-― 611 ―日本外科系連合学会誌 第 43 巻 ４ 号

Fig. 1 Abdominal plain CT demonstrating wall
thickening, luminal narrowing and hyperdensityof the jejunum.
Dilation of the small bowel proximal to thethickening was also recognized, suggestive ofa small bowel obstruction.

Fig. 2 Resected specimen showing segmental
intramural hematoma localized to a part of thejejunum with intact mucosa.
travenous vitamin K. Consequently, the PT-INR
improved to 1.39.
Because of decreasing blood pressure and worsening of the anemia, the patient underwent exploratory laparotomy on suspicion of an exacerbation of anticoagulant-induced intraabdominal hemorrhage.
The peritoneal cavity contained about 300ml ofbloody fluid and an approximately 20cm segment of
the jejunum was markedly thickened and dark-red
in color (Fig. 2 ). The adjacent mesentery was also
thickened with hematoma but there was no evidenceof active bleeding from the mesenteric vessel. In
order to relieve the intestinal obstruction and be-Fig. 3 Pathological examination showing submucosal hemorrhage and intact mucosa and themuscularis mucosa of the jejunum.
cause of concerns of bowel ischemia, partial resection of about 50cm of the small intestine was performed. Histopathologic examination showed
extensive submucosal hemorrhage of the jejunum
without thrombus or necrosis (Fig. 3 ).
His postoperative course was complicated by respiratory failure but he eventually recovered. He
was discharged on the 56th postoperative day withoral intake of rivaroxaban 10mg daily.

Discussion
Small bowel intramural hematomas found on autopsy were first reported in 1838 by McLauchlan who
described them as “false aneurysmal tumor” occluding the duodenum4）. The jejunum is the most common site of spontaneous intramural small bowel hematoma, followed by the ileum, and duodenum,
whereas traumatic small bowel hematoma commonly affects the duodenum 5,6）.
Over-anticoagulation with warfarin is the mostcommon cause of spontaneous intramural smallbowel hematoma, while unfractionated heparin accounts for few cases7,8）. Other aetiological factors 5）
include hemophilia, idiopathic thrombocytopenic
purpura, von Willebrandʼs disease 9）, Henoch-Schonlein purpura10）, malignancies, and vasculitis. Smallbowel hematomas are also associated with pancreatitis and pancreatic carcinoma11）. It is most likelythat there is a rupture of the terminal artery thatbranches from the mesentery and penetrates into
the muscular layer of the intestinal wall. Therefore,
bleeding dissects the intestinal wall between themuscularis mucosa and muscular layers 12,13）. Pro-― 612 ―

16)

M

M

FM

39

71

55

72

72

62

unknown

69

57

76

73

Uzun MA

Leonardo G18)

Çarkman S15)Çarkman S

Pendlimari R19)

Altintoprak F20)

Altintoprak FYoldaş T12)

― 613 ―

Yoldaş TYoldaş TAbdel Samie A8)

MMFM

MM

M79

Uzun MA17)

M

F65

13

GenderAge
INR 2.7 APTT 43.7s

Laboratory Findings

phenprocoumon

warfarinacetylsalicylic acidwarfarin

warfarin

warfarin

warfarin

warfarin/acetylsalicylic acidwarfarin

acenocoumarol

warfarin

warfarinjejunum

small intestine

jejunum

Portionjejunum

jejunum

INR＞6 APTT 121s

INR 1.4

INR 2.2

INR 1.82

unknown

INR 7.2

INR＞13

jejunum

small intestine

small intestine

small intestine

small intestine

small intestine

jejunumMortality

Reason of operationexploration

discharge

bowel obstruction and acute abdomenbowel obstruction and acute abdomen

the development of acute abdomen signs
during conservative therapy

acute abdomen signs at admission

progressive hypotension in spite ofconservative therapy

the presence of a massive intraperitoneal
hematoma

intestinal obstruction in spite ofconservative therapy

discharge bowel obstruction and acute abdomenpartial resection discharge

exploration

death

partial resection deathpartial resection discharge

partial resection deathpartial resection discharge

exploration

progressive hypotension in spite ofconservative therapy

discharge mesenteric ischemia

partial resection discharge

gastrointestinal bleeding and suspended
partial resection discharge obstruction in spite of conservative
therapy

partial resection discharge intestinal obstruction and ischemia

partial resection discharge bowel obstruction

partial resection discharge unknown

Operation

INR unmeasurably highjejunum and ileum exploration
APTT＞120s

INR 8.5 APTT 112s

APTT 125s

INR unmeasurably high small intestine

INR 2.58

low molecular weight heparin PTT 41.7s

warfarin

Anticoagulation

Recent reports of operation for spontaneous intramural hematoma（2003－2016）

Shaw PH7)Polat CAuthor

Table 1

Spontaneous Intramural Hematoma of the Jejunum Induced by Anticoagulant Therapy

日本外科系連合学会誌 第 43 巻 ４ 号
gression of symptoms is due to an intramural osmotic gradient caused by the liquefying hematoma,
which causes thickening of the intestinal wall anddecreasing the intestinal luminal dimeter by drawing fluid from the surrounding tissues14）.
On admission, almost all patients have abdominal
pain, and about one half of the patients have nausea
and vomiting, which are related to high obstructions
involving the duodenum and proximal jejunum.
Hemorrhage in the digestive tract is reported in up
to 40% of cases, exteriorized in the form of melena,
hematemesis and hematochezia 3）.
In the presence of signs of peritoneal irritation,
hematoma complications like necrosis, perforationand hemoperitoneum should be suspected12）.
Most patients have an elevated PT-INR, values ofwhich greater than 3 are associated with an increased risk of bleeding 15）. Hemoglobin levels atpresentation are often normal or borderline anemic.
Bleeding could also occur even though the coagulation parameters are within the therapeutic range16）.
CT is the most useful diagnostic modality ofchoice, which is sufficiently sensitive and beneficial
to diagnose and follow intramural hematoma. Characteristic findings are circumferential bowel wall
thickening, intramural hyperdensity, luminal narrowing and intestinal obstruction 5）.
Initially, noncontrast CT should be performed before oral and intravenous contrast medium application, as contrast-enhanced CT alone may mask thepresence of intramural hemorrhage3）.
Owing to the rarity of this entity, there is no standardized treatment. However, most reports haverecommended conservative therapy as the mainstayof therapy, including bowel rest, nasogastric decompression, correction of electrolyte disturbances, immediate suspension of oral anticoagulants, correct ion of abnor ma l coag ulat ion pa ra meters byadministering vitamin K, fresh frozen plasma (FFP)
and blood transfusion 3,12,15）. The resolution of a hematoma might start as early as 1 week after the onset and complete resolution usually occurs within 2months 5）.
Surgical intervention should be considered in patients with significant intramural hemorrhage, suspected ischemia, perforation, peritonitis, or intestin a l ob st r uc t ion t h at do e s not re s olve w it hconservative treatment 3,12,16）. In the present case, wedecided to resect the damaged segment, since it wasnecessary to prevent the worsening general condition of the patient.
The PubMed were used in order to review the literature describing the case who had underwent surgical treatment by a diagnosis of intramural hematoma of small intestine from 2003 to 2016 (Table 1 ,14cases). More seriously ill patients should tend tohave surgical indication, however, recent studies
present acceptably good prognosis of patients whounderwent surgical therapy (out of 14 patients, 11were discharged alive) 7,8,12,15-20）.
In our case, it is speculated that the main cause
the onset was drug interaction with warfarin. The
potential for warfarin to adversely interact withother drugs including antiplatelet agents, antibiotics
and agents against gout, causing fluctuations in the
anticoagulant effect, is widely recognized 21）. Thispatient had taken multiple medications and aspirin,
clarithromycin and allopurinol, which had the possibility of augmenting excessive effect of warfarin.
On the other hand, polypharmacy is a major problem in the elderly population and increases thechance of drug interaction19）. We presume that ruptures of the terminal artery in the intestinal walloccasionally happen, but that the bleeding wouldstop if the coagulant function is normal. However,abnormal anticoagulation by excessive effect of warfarin causes an augmentation of intramural hematoma.
In conclusion, although intramural small bowel
hematoma requiring a surgery is a rare complication of anticoagulant therapy, the possibility of thisentity in patients presenting with acute abdominal
pain should be considered for an accurate diagnosis
and treatment. We should consider a surgical procedure should be indicated if conservative treatment
is not successful or if there is the worsening of general condition.
Conflict of interest: None.
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