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A retrospective review of patients with non-traumatic spontaneous intramural hematoma

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Non-traumatic spontaneous intramural hematoma of the small intestine is a rare clinical condition, most commonly caused by over-anticoagulation. In this study, the clinical approach algorithm for patients diagnosed with a spontaneous isolated
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  ORIGINAL ARTICLE Manuscript received: 18.10.2012  Accepted: 12.01.2013 Turk J Gastroenterol2013; 24 (5): 392-399doi:10.4318/tjg.2013.0697The study has been presented an oral presentationat 18 th  National Surgery Congress, 2012, ‹zmir, Turkey  Address for correspondence: Fatih ALTINTOPRAK Sakarya University Faculty of Medicine, Department of GeneralSurgery, Sakarya, TurkeyE-mail: fatihaltintoprak@yahoo.com  A retrospective review of patients with non-traumatic spontaneous intramural hematoma Fatih ALTINTOPRAK  1 , Enis D‹K‹C‹ER 2 , Muhammed AKYÜZ 3 , U¤ur DEVEC‹ 4 , Yusuf ARSLAN 2 ,  Yasemin GÜNDÜZ 5 , Murat YÜCEL 6 , Osman Nuri D‹LEK  1  Departments of 1 General Surgery, 5  Radiology and 6  Emergency Medicine, Sakarya University School of Medicine, Sakarya Department of  2 General Surgery, Sakarya University Research and Educational Hospital, Sakarya Department of  3 General Surgery, Erciyes University School of Medicine, Kayseri Department of  4 General Surgery, Maltepe University School of Medicine, ‹stanbul Girifl ve Amaç:  Non-travmatik spontan intramural hematom oldukça nadir görülen bir klinik durumdur ve en s›k nedeni afl›r› an-tikoagülasyondur. Bu çal›flmada; afl›r› antikoagülasyona ba¤l› olarak spontan ince barsak intramural hematom tan›s› koyulanhastalardaki klinik yaklafl›m algoritmas›n› ve hastalar›n uzun dönem sonuçlar›n› sunmay› amaçlad›k. Gereç ve Yöntem:  2007- 2011 y›llar› aras›nda 3 farkl› t›p fakültesi hastanesinde intramural hematom tan›s› koyulmufl olan hastalar›n kay›tlar› retrospek-tif olarak incelendi. Travma anamnezi olan, ince barsak d›fl› organlarda da hematom saptanan ve afl›r› antikoagülasyon d›fl› etyo-lojik faktör saptanan hastalar inceleme d›fl› b›rak›ld›ktan sonra; izole olarak ince barsak intramural hematomu saptanan 15 has-ta de¤erlendirilmeye al›nd›.  Bulgular: On hastada (%66.6) ilk baflvuru merkezi acil servisler iken 5 hastada (%33.3) di¤er klinik-lerdi. Onüç hastaya (%86.6) medikal tedavi uygulan›rken 2 hastaya (%13.3) cerrahi tedavi uyguland›. Hastanede yat›fl sürecinde 2hastada (%13.3) tedavi mortalite ile sonuçland›. Ortalama 22 ay (4-48) düzenli klinik takipleri olan 11 hastan›n hiçbirinde intra-mural hematom klini¤i tekrarlamad›, 3 hasta (%27.7) takip sürecinde intramural hematomla iliflkisiz nedenlerden dolay› öldü. So-nuç:  Hastalar›n ilk baflvuru merkezleri farkl› olabildi¤i ve bafllang›ç klinik bulgular› non-spesifik oldu¤u için intramural hema-tom tüm klinisyenler taraf›ndan bilinmesi gereken bir tan›d›r. Non-invaziv yöntemlerle erken dönemde ve do¤ru tan› koyulmas› ge-reksiz cerrahi giriflimleri engelleyecektir. Anahtar kelimeler: Antikoagülan, afl›r› antikoagülasyon, warfarin, hematom, intramural hematom  Background/aims:  Non-traumatic spontaneous intramural hematoma of the small intestine is a rare clinical condition, most com-monly caused by over-anticoagulation. In this study, the clinical approach algorithm for patients diagnosed with a spontaneous iso-lated intramural hematoma of the small intestine associated with over-anticoagulation and the long-term outcomes of the patientsare presented.  Material and Methods: The records of patients who were diagnosed with intramural hematoma in 3 different me-dical faculty hospitals between 2007 and 2011 were retrospectively analyzed. After excluding patients with trauma history, hema-toma in organs other than the small intestine, and with etiological factors other than over-anticoagulation, 15 patients with an iso-lated intramural hematoma of the small intestine were evaluated within the scope of the study.  Results: The sites of first admissi-on were emergency departments for 10 patients (66.6%) and other clinics for 5 patients (33.3%). Thirteen patients (86.6%) receivedmedical treatment and two patients (13.3%) underwent surgical treatment. During the hospitalization period, a total of two pati- ents (13.3%) died. Out of the 11 patients with an average follow-up of 22 months (range: 4-48 months), no patient had a relapse of intramural hematoma and three patients (27.7%) died due to reasons not related to intramural hematoma. Conclusion:  Intramu-ral hematoma diagnosis should be known by all physicians, because the site of first admission may be different clinics, since the cli-nical presentation begins with non-specific complaints. Early and accurate diagnosis by non-invasive methods will preclude unne-cessary surgical interventions. Key words: Anticoagulant, over-anticoagulation, warfarin, hematoma, intramural hematoma Non-travmatik spontan intramural hematomlu hastalar›n retrospektif de¤erlendirilmesi  INTRODUCTION Oral anticoagulants have long been used forprophylaxis and treatment of various indications.Parallel to the advances in intensive care conditi-ons, as well as with radiological and surgical deve-lopments, the number of patients with indicationsof oral anticoagulation treatment has increasedover the past two decades (1). Corresponding tothis common usage, it is clear that patients whodevelop complications due to the use of anticoagu-lants will be more frequently encountered. A ma- jor complication that can be observed during theuse of oral anticoagulants is bleeding (2). Intramural hematoma (IMH) has been first des-cribed in 1838 (3) and is most commonly caused byabdominal trauma. Non-traumatic cases are cal-led spontaneous hematoma and their most com-mon cause is overanticoagulation. Other risk fac-tors include hemophilia, idiopathic thrombocyto-penic purpura, leukemia, chemotherapy, vasculi-tis, and pancreatitis (4). Spontaneous IMH of thesmall intestine is a very rare clinical condition andits incidence is 1/2500 (5). Generally they are notlife-threatening complications and may improvewith medical treatment. This study presents the clinical follow-up course,radiological findings, and long-term results of fif-teen patients with an isolated spontaneous IMH of the small intestine that represent the experiencesof three different university hospitals. PATIENTS and METHODS The records of patients who had been diagnosedwith IMH in the General Surgery Clinics of Sakar-ya University Medical School, Erciyes UniversityMedical School, and Maltepe University MedicalSchool between 2007 and 2011 were retrospecti-vely analyzed. Fifteen patients with spontaneousIMH of the small intestine were evaluated withinthe scope of the study, after excluding patientswith trauma history, hematomas in organs otherthan the small intestine (including the colon), ret-roperitoneal hematoma, and etiological factors ot-her than over anticoagulation treatment. The demographic characteristics, indication foranticoagulation, duration of anticoagulant use,presenting signs and symptoms, time to the onsetof signs and symptoms, laboratory and radiologi-cal findings, management interventions, hospitali-zation course, and the long-term outcomes of thepatients were evaluated.  Intramural hematoma 393 The following parameters were used in the compu-ted tomography (CT) examination protocols: 4 x 5-mm collimation, 5-mm slice thickness, 2.5-mmscan interval, 120 kVp, and 250 mAs. Approxima-tely 125 mL of intravenous iohexol (Omnipaque300; GE Healthcare, Little Chalfont, United King-dom), Iopromide (Ultravist 300; Bayer-Schering,Berlin, Germany), or Iomeprol (Iomeron 350;Bracco, Milano, Italy) was given to patients whohas no contraindications for intravenous contrastagent use. The below medical treatment algorithm was follo-wed in all patients other than the two (13.3%) whorequired surgical intervention: 1) termination of warfarin sodium treatment andoral food intake, 2) nasogastric decompression inpatients with the complaint of vomiting, 3) fresh-frozen plasma transfusion and vitamin K adminis-tration, 4) erythrocyte transfusion in patientswith anemia, 5) daily follow-up of blood count andclotting parameters, 6) frequent mobilization, 7)initiation of parenteral nutrition in patients wit-hout oral nutrition for more than four days, 8) ini-tiation of oral nutrition according to clinical fol-low-ups (decrease in abdominal distention, passa-ge of gas-stool), 9) rearrangement of oral antico-agulation treatment when the INR value decrea-sed to the therapeutic level. RESULTS Of the fifteen patients who were evaluated in thisstudy, seven (46.6%) were male and eight (53.3%)were female, with a mean age of 63.1 (range: 57-74) years. The site of first admission was emergency depart-ments for ten patients (66.6%), cardiology outpati-ent clinics for two (13.3%) patients, nephrologyoutpatient clinics for two (13.3%) patients, and ge-neral surgery outpatient clinic for one (6.6%) pati-ent. Following the first admission, seven patients(46.6%) were hospitalized in general surgery cli-nics, five (33.3%) in cardiology clinics, two (13.3%)in gastroenterology clinics, and one (6.6%) patientin the nephrology clinic, and their treatment plan-ning was initiated by the respective clinics. Eightpatients (53.3%) hospitalized in clinics other thangeneral surgery clinics due to elevated creatinineand/or International Normalized Ratio (INR) valu-es, were transferred to general surgery clinics aftera mean period of two days (range: 1-3 days) as the-ir complaints of abdominal pain did not improve.   ALTINTOPRAK et al. 394 The patients had been using warfarin sodium for anaverage period of 17 months (range: 5-60 months)with intermittent dose adjustments and a mean do-se of 5 mg/day. The most common indications forthe use of warfarin sodium were cardiologic reasons(13 patients, 86.6%). The indications for the use of warfarin sodium are summarized in Table 1.  All patients complained of visceral-type abdomi-nal pain at the time of admission. The mean timebetween the onset of complaints and hospital ad-mission was 5 days (range: 1-12 days). Two pati-ents (13.3%) had ecchymosis on the abdominalskin, one patient (6.6%) on the left hemithoraxand back, one patient (6.6%) on the left lumbar re-gion, and one patient (6.6%) on both upper extre-mities and right lumbar region. The complaintsand signs at admission in all patients are summa-rized in Table 2. Laboratory examinations revealed that the INRvalue was above normal (normal range: 0.85-1.25)in all patients, and the mean value was measuredas 6.2 (range: 2.29-9.83). The INR level of the pa-tient with rectal bleeding was above the normalvalues although it was within the therapeutic do-se range (INR=2.2). Furthermore, anemia(Hb<12g/dL) was present in 11 patients (73.3%),and leukocytosis (leukocyte count > 10.000 / mm 3 )- in 8 patients (53.3%). The values for the patients’blood count and clotting parameters are summari-zed in Table 3.The abdominal radiography and abdominal CTexaminations were performed in all patients, whi-le abdominal ultrasonography was performed inonly 6 patients. Seven patients (46.6%) had smallintestine-type air-fluid levels and the remaining 8patients (53.3%) had normal abdominal radiog-raphy. Upon US examination, 6 patients (6/15,40.0%) had both segmental wall thickening in thesmall intestines and small intestinal dilatation,while only one patient was found to have intraab-dominal free fluid.  Abdominal CT scan revealed single intramuralwall thickening in eleven patients (Figure 1A) andmultiple hematomas in four patients [different je- junum segments in two patients (13.3 %), jejunumand ileum segments in one patient (6.6 %), jeju-num and duodenum segments in one patient (6.6%), (26.6 %)] (Figure 1B). Intraabdominal free flu-id was detected in five patients (33.3 %) at CTscan. Furthermore, among the patients who werefound to have intraabdominal free fluid, three(3/5, 60%) had pleural effusion (Figure 2A and B).Radiologic findings are summarized in Table 4. Thirteen patients (86.6%) received medical treat-ment and 2 patients (13.3%) underwent surgicaltreatment. Surgical treatment was used due to thepresence of acute abdomen signs at admission inone patient and due to the development of acuteabdomen signs during medical treatment (at 3 rd day) in the other patient. Complaints(n; %)Signs(n; %)  Abdominal pain15; 100Abdominal tenderness15; 100 Vomiting8; 53.3Moderate abdominal distension11; 73Weakness6; 40Anemic appearance6; 40.0 Anorexia4; 26.6Ecchimosis5; 33.3Hematochezia2; 13.3Dehydrated appearance2; 13.3Diarrhea1; 6.6Melanotic stool2; 13.3Constipation1; 6.6Rebound tenderness1; 6.6Haematuria1; 6.6Haematuria1; 6.6 Table 2. Complaints and signs of admission in all patients (n=15, 100%) Indicationsn; % Coronary artery stent (CAS)4; 26.6Coronary by-pass (CAB)3; 20.0Mitral valve replacement2; 13.3Cerebrovascular accident (CVA)1; 6.6Lower-extremity deep vein thrombosis1; 6.6 Atrial fibrillation1; 6.6CVA+CAS1; 6.6CVA+CAB1; 6.6CAB+aortic valve replacement1; 6.6 Table 1. The indications for the use of warfarin sodi-um in all patients (n=15, 100 %)   Intramural hematoma During the hospitalization period, a total of twopatients (13.3%) died (a patient who underwentsurgery and a patient with chronic renal failurewho received medical treatment). Nasogastric decompression was performed for amean period of three days (range: 2-4 days).Fresh-frozen plasma (FFP) transfusion was plan-ned so as to administer a maximum 3 units perday until the INR level falls to the therapeuticrange. Each patient required 6 units (range: 5-13)units of FFP transfusion on average. The patientswho were found to have anemia at the time of ad- Patient NoAgeSexHbHtcWBCPlateletINR 174M8.224.528.100248.000>5259M7.926.713.200203.000>5368M8.323.65700211.0008.5464F10.429.414.300252.0009.2568F8.021.78.20046.0002.2667F9.128.410.210245.0003.5758M11.734.98.000109.0009.8862M10.228.211.200134.0007.2958M13.233.17.800145.0006.91067M12.032.113.400121.0007.21162F12.433.211.200230.0006.21257F8.324.516.500234.0003.21359F13.336.413.400322.0004.51465F10.230.29.200229.0005.41557F11.735.48.700313.0005.3 Table 3. Patients’ blood count and clotting parameters  Abbreviations; M: Male, F: Female, Hb: Hemoglobin (g/dL), Htc: Hematocrit (g/dL), WBC: White blood cell count (cells/mm 3 ), Platelet: Platelet count(cells/mm 3 ), PT: Prothrombin time (seconds), aPTT: Activated partial thromboplastin time (seconds), INR: International Normalized Ratio Figur   e 1. Abdominal CT imaging; (A) a 68-year-old male patient; homogenous and symmetrical wall thickening in the jejunum segmenton CT examination. The hyperdense appearance in the wall, which is characteristic of early hematomas, can be clearly identified (arrowheads). (   B)A 58-year-old male patient; symmetrical and homogenous wall thickening can be seen in different jejunal segments on CTexamination (arrow heads).   AB 395   ALTINTOPRAK et al. 396 mission were administered erythrocyte transfusi-on and each patient received 3 units (range: 2-5units) of erythrocyte transfusion on average. Nopatient required platelet transfusion. INR levels decreased to the therapeutic range af-ter a mean period of 3.7 days (range: 2-7 days).The mean duration of hospitalization was 6.8 days(range: 4-13 days). Except for the two patients who were lost to fol-low-up, among the eleven patients with an avera-ge follow-up of 22 months (range: 4-48 months), nopatient had a relapse of IMH and three patients(27.7%) died due to reasons not related to IMH. DISCUSSION Intramural hematoma is a clinical conditionknown for approximately 100 years and the cur-rently accepted theory for its development is a se-paration of the intestinal wall layers by hemorrha-ge caused by damage in the terminal arteries inthe intestinal wall (6). Since the clinical triad (abdominal pain, signs of small intestinal obstruction, and multiple hemorr-hagic symptoms) typical of IMH may not be obser-ved in all patients, keeping this rare possibility inmind is the first and basic requirement for enab-ling diagnosis (7-10). This is due to the fact thatabdominal pain, nausea and vomiting are themost common symptoms in IMH cases (7-11) andthese are non-specific symptoms that are nearlythe most frequently encountered symptoms inemergency departments. Abdominal pain and vo-miting were also the most common symptoms inthe cases in this study, with rates of 100% and53.3%, respectively.  After considering the possibility of an intraabdo-minal problem associated with over-anticoagulati-on, blood count and coagulation parameters sho-uld be measured. Although the most common rea-son for IMH is the use of warfarin sodium, it sho-uld be kept in mind that it may also develop in so- Figure 2. A 64-year-old female patient; abdominal CT imaging; (A) there is fluid in the right hemithorax (double arrow) together with in-traabdominal free fluid around the liver-spleen (arrows) on the upper sections; (B) symmetrical and homogenous wall thickening in dif-ferent jejunal segments on the lower sections (arrow heads).   Radiologic tooln; %  Abdominal radiography (n=15; 100%)• Air-fluid levels7; 46.6• Normal8; 53.4 Abdominal USG (n=6; 100%)• Segmental small bowel wall thickening6; 100• Dilated bowel loops6; 100• Intraabdominal free-fluid1; 16.6 Abdominal CT (n=15, 100%)• Segmental small bowel wall thickening15; 100• Partial obstruction signs15; 100• Intraabdominal free fluid5; 33.3• Single hematoma11; 73.3• Multiple hematoma4; 26.6 Table 4. Radiologic findings in patients with sponta-neous intramural hematoma at admission AB
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