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Discussion
Intramural small bowel hemorrhage, once considered rare, has been reported with increasing frequency over the last two decades. Use of anticoagulants and anti-platelet agents has been increasing. Cause of intramural bowel hematomas can be divided into six major categories:
- Platelet Deficiency
ITP, TTP, HUS, Leukemia, Hypersplenism(massive)
- Platelet Dysfunction
Glansmann's thrombasthenia, Bernard-Soulier syndrome
- Coagulation Defects
Hemophilia, Von Willebrand's disease, Dysfibrinogenemia, DIC, Hepatic failure
- Pharmacotherapy
heparin, coumadin, streptokinase, urokinase, TPA
- Trauma
blunt abdominal trauma, endoscopic manipulation, forceful vomiting
- Vasculitis
PAN, HSP, Ehlers-Danlos syndrome
The most common hemorrhagic small intestine complication of anticoagulant therapy is spontaneous or trauma induced intramural hematoma. (1) In the absence of abdominal trauma this is most likely to occur in the jejunum. In response to blunt abdominal trauma, the duodenum is most susceptible. The duodenum is highly vascular and lacks a complete circumferential serosal layer. "This results in varying elasticity of the duodenal wall, and may enable an intramural hematoma to expand. The duodenum also rests on a short, rigid mesentery. The relatively fixed ends at the pylorus and the ligament of Treitz result in a closed loop. Therefore sudden pressure changes can result in shearing of the bowel wall layers. (2)
Symptoms may be quite variable. Colicky abdominal pain and obstructive symptoms may predominate. Biliary symptoms or pancreatitis may result from obstruction of the biliary or pancreatic ducts. Abdominal tenderness, low - grade fever and a palpable abdominal mass are common physical findings. The onset is frequently insidious and symptoms vary depending upon the rapidity of hemorrhage and the volume of blood in the bowel wall. Minor intestinal bleeding occurs in 25% and major bleeding occurs in 3.5% (3)
Plain abdominal x-rays may reveal evidence of a proximal small bowel obstruction. UGI series is considered the most useful diagnostic test. A coiled-spring, picket fence or stack- of- coins sign is most suggestive. This radiographic appearance is due to extravasation of blood into the valvulae conniventes. This will result in narrowing of the lumen with spike like projections of barium outlining the normal caliber of the lumen. (4)Serial ultrasound examinations are normally done to monitor progression or resolution of the hematoma. (5) A 1997study by Lane et al. suggested that patients who are clinically at risk for intramural small bowel hemorrhage should undergo a noncontrast CT scan of the abdomen prior to the routine oral and intravenous contrast-enhanced scan. (2) On a contrast enhanced CT scan, small bowel wall thickening can indicate an ischemic, inflammatory, infectious, or a neoplastic process. Increased attenuation on a non-contrast CT is a reliable indicator of hemorrhage.
Conservative medical management is usually sufficient. Most hematomas spontaneously reabsorb. Symptoms can resolve within a few days or may take up to a few weeks. Radiographic features resolve within a few weeks. Correction of the underlying bleeding disorder with vitamin K and FFP, IV hydration, and NGT decompression for obstructed patients are sufficient for management of most patients. If intestinal bleeding, fevers, or obstructive symptoms do not resolve, then surgical intervention should be considered. (6)
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