Hospital: HOSPITAL DE 12 OCTUBRE.
Ciudad:
Nº:
Aut@r o Autores: M.A. Depetris, E. Martinez Chamorro, J. Zulay Rodriguez Calderon, L. Ibañez Sanz, A. Merina Castilla, S. Hernaez Leonato.,
Presentación:
A 92 year-old man with medical history of ischemic cardiomyopathy, chronic heart failure, ischemic stroke, intermittent claudication and atrial fibrillation undergoing anticoagulation with acenocumarol presented at emergency department with a 24-hour history of abdominal pain. He reported no diarrhoea, nausea or vomiting. On physical examination the patient was hemodynamically stable, with acute pain of the right iliac fossa and signs of peritoneal irritation. Laboratory test showed prolonged prothrombin time (60.8 sec, normal range 9.812.3) and international normalized ratio (INR) 11.9 (normal range 1.5-3). Abdominal CT showed circumferential wall thickening of the jejunum and mucosal enhancement, hypoattenuating submucosal layer, mesenteric congestion and fat stranding. There were small amount of hemoperitoneum in pelvis and perisplenic location. Mesenteric vessels remained patent.
Discusión:
Spontaneous intestinal intramural hematoma is a rare complication under anticoagulant therapy. It has been report in 1 per 2500 patients on anticoagulant therapy each year. The incidence is predicted to increase further, as a result of wide use of long-term anticoagulation.It mostly occurs in the small intestine and rarely in the colon, most usually involves jejunum, followed by the ileum and duodenum. Bleeding originates in the submucosa from small vessels that produce slow bleeding. The spectrum of clinical presentation is wide and can vary from mild, vague abdominal pain to intestinal obstruction and acute abdomen pain. Signs of peritoneal irritation usually indicate the development of complications such as necrosis, perforation or hemoperitoneum, and the latter as our case. Characteristic findings on CT include circumferential wall thickening, intramural hiperdensity (better shows at a unenhacement CT), luminal narrowing and intestinal obstruction.Wall thickening may be also found in other conditions, including malignancy and inflammatory and ischemic bowel disease. However in contrast to the latter, complete normalization of the imaging findings usually occurs in 2 months afterthe onset, because the haemorrhagic bowel is not necrotic and complete restitution occurs in almost all cases under conservative management.
Conclusión:
Spontaneous intestinal intramural hematoma is a rare complication under anticoagulant therapy. It has been report in 1 per 2500 patients on anticoagulant therapy each year. The incidence is predicted to increase further, as a result of wide use of long-term anticoagulation.It mostly occurs in the small intestine and rarely in the colon, most usually involves jejunum, followed by the ileum and duodenum. Bleeding originates in the submucosa from small vessels that produce slow bleeding. The spectrum of clinical presentation is wide and can vary from mild, vague abdominal pain to intestinal obstruction and acute abdomen pain. Signs of peritoneal irritation usually indicate the development of complications such as necrosis, perforation or hemoperitoneum, and the latter as our case. Characteristic findings on CT include circumferential wall thickening, intramural hiperdensity (better shows at a unenhacement CT), luminal narrowing and intestinal obstruction.Wall thickening may be also found in other conditions, including malignancy and inflammatory and ischemic bowel disease. However in contrast to the latter, complete normalization of the imaging findings usually occurs in 2 months afterthe onset, because the haemorrhagic bowel is not necrotic and complete restitution occurs in almost all cases under conservative management.
Bibliografía:
– Yu W, Feng C, Han T, Ji S, Zhang L, Dai Y. Surgically treated rare intestinal bleeding due to submucosal hematoma in a patient on oral anticoagulant therapy.Medicine 2018,97 (46), 1-5. – Samie AA, Theilmann L, Samie AA. anticoagulant therapy Detection