Clinics in diagnostic imaging (201). Small bowel intramural haematoma induced by anticoagulation therapy with associated reactive ileus

Abstract

A 74-year-old woman receiving long-term anticoagulation with warfarin for chronic atrial fibrillation presented with severe acute abdominal pain, diarrhoea and vomiting. Initial laboratory workup revealed a deranged coagulation profile. Computed tomography of the abdomen and pelvis demonstrated spontaneous distal jejunal intramural haematoma with associated reactive ileus. No overt pneumatosis intestinalis, intraperitoneal free gas or haemoperitoneum was seen. Based on clinical and imaging findings, a diagnosis of over-anticoagulation complicated by small bowel intramural haematoma was made. The patient was managed non-operatively with analgesia, cessation of warfarin and reversal therapy with vitamin K. Warfarin therapy was recommenced upon resolution of symptoms and optimisation of coagulation status. The clinical presentation, radiological features and overall management of anticoagulation-induced bleeding are further discussed in this article.

Keywords: anticoagulants; atrial fibrillation; haematoma; haemorrhage; warfarin.

Fig. 1

(a) Axial and (b) coronal CT images of the abdomen and pelvis.

Fig. 2

A 75-year-old woman on warfarin therapy for atrial fibrillation presented with abdominal pain. (a) Axial and (b) coronal CT images of the abdomen show a large abdominal wall haematoma (arrows). Laboratory workup revealed an acutely low haemoglobin level and prolonged prothrombin time of 39.2 seconds and international normalised ratio of 3.60.

Fig. 3

A 61-year-old man with mitral valve stenosis and prior cerebrovascular disease who was on warfarin and ticlopidine therapy presented with soft tissue swelling and ecchymosis of the left chest wall. Laboratory workup revealed a prolonged international normalised ratio of 3.17. (a) Axial and (b) coronal thoracic CT images show a left posterolateral chest wall haematoma (black arrows). There is a small blush of contrast within the chest wall haematoma (white arrows) indicating a focus of active haemorrhage.

Fig. 4

An 82-year-old woman on warfarin therapy for mitral stenosis and atrial fibrillation with associated drop in haemoglobin level and prolonged coagulation profile (international normalised ratio 7.32, prothrombin time 74.2 seconds, activated partial thromboplastin time 61.0 seconds) presented with right hip and flank pain. (a) Axial and (b) coronal CT images of the abdomen show an acute right psoas haematoma (arrows).

Fig. 5

An 87-year-old woman presented with acute left calf swelling and pain following warfarin therapy for left lower limb deep vein thrombosis. Coagulation parameters were prolonged, with an international normalised ratio of 3.25 and prothrombin time of 31.6 seconds. Axial (a) T1-W and (b) gradient echo MR images as well as (c) US image of the left calf show a large heterogeneous, subcutaneous left calf haematoma (arrows).

Fig. 6

A 68-year-old man was on warfarin therapy for atrial fibrillation, with raised international normalised ratio of 3.50 and prolonged prothrombin time measuring 38.4 seconds at the time of clinical presentation. (a) Axial and (b) coronal CT images of the pelvis show gross haematuria within the urinary bladder (arrows).

Fig. 7

A 66-year-old man on warfarin therapy for atrial fibrillation presented with acute left flank pain, low haemoglobin level of 6.6 g/dL, slightly prolonged prothrombin time of 11.6 seconds and subtherapeutic international normalised ratio of 1.11. (a) Axial and (b) coronal abdominopelvic CT images show a large left perinephric haematoma (asterisks) secondary to a ruptured left haemorrhagic renal cyst with retroperitoneal haematoma. The patient subsequently underwent digital subtraction angiography of the single left renal artery. Angiograms show (c) no obvious contrast blush; however, (d) two 6 mm × 14 mm Nester coils were deployed into the left renal artery prophylactically.

Fig. 8

An 80-year-old man on warfarin therapy for atrial fibrillation presented with low back pain and hypotension. His activated partial thromboplastin time and prothrombin time were prolonged at 35.7 seconds and 12.5 seconds, respectively. (a) Axial and (b) coronal abdominopelvic CT images show large right retroperitoneal haematoma (asterisks). There is a blush of contrast within the inferior aspect of the haematoma (arrow), indicating a focus of active haemorrhage. The patient subsequently underwent digital subtraction angiography. Angiograms show (c) blush at the right L3 lumbar vertebral artery in a contrast run, which was in keeping with active haemorrhage; and (d) successful occlusion of the bleeding vessel with one 2 mm × 3 cm and two 3 mm × 5 cm MicroNester coils.

Fig. 9

(a & b) A 69-year-old man on lifelong warfarin therapy (international normalised ratio [INR] 2.34, activated partial thromboplastin time 40.7 seconds, prothrombin time 24.9 second) for aortic and mitral valve replacements presented with left-sided weakness. Non-contrast enhanced (a) axial and (b) coronal CT images of the brain show a large acute right frontoparietal parenchymal haematoma (asterisks). (c & d) A 64-year-old man on lifelong warfarin therapy (INR 5.26) for atrial fibrillation presented with a severe headache. Non-contrast enhanced (c) axial and (d) coronal CT images of the brain show acute subdural haematoma (arrows) along the cerebral falx and left cerebellar tentorium.