Anticoagulant-induced intestinal hematoma – a common complication of anticoagulant therapy?

Introduction: Intestinal/rectal hematoma is a rare complication of anticoagulant therapy. We report two cases of intramural small bowel hematoma and one case of a large retro rectal hematoma, all complications of treatment with phenprocoumon, which nowadays is used extensively for therapeutic and prophylactic purposes. However, various hemorrhagic complications can result. Intestinal hematoma, once considered a rare complication of anticoagulation, has recently been reported increasingly.

Case Reports:

Case 1: An 80-year-old woman was admitted to the hospital due to jaundice and abdominal pain. The patient was on phenprocoumon due to chronic atrial fibrillation. Laboratory studies revealed abnormal coagulation tests (INR >6, 0). Sonography demonstrated a heterogeneous mass within the duodenal wall. CT confirmed the sonographic findings showing circumferential wall thickening of the duodenum consistent with intramural hematoma causing biliary obstruction. On MRI a well-defined concentric ring configuration (ring sign) was detected. Phenprocoumon therapy was stopped and the patient was successfully treated conservatively.

Case 2: An 85-year-old woman was admitted to our unit due to abdominal pain, nausea and vomiting. The patient was under anticoagulation with phenprocoumon because of atrial fibrillation. Laboratory tests showed prolonged prothrombin time (INR >6) and normocytic anaemia (Haemoglobin 8,9g/dl). Further investigations using sonography and CT scan revealed intramural jejunal hematoma causing intestinal obstruction. Conservative therapy proved successful in complete resolution of obstructive symptoms.

Case 3: An 83-year-old female patient was admitted to our hospital with rectal bleeding. She complained about pain in her lower back because of a heavy fall two weeks before. Due to atrial fibrillation and low cardiac output she had been under constant treatment with phenprocoumon with the INR within therapeutic range. CT scan and endosonography showed al large retro rectal mass consistent with a hematoma leading to local pressure necrosis of the rectal wall and formation of a fistula. The patient underwent surgery with transrectal evacuation of the hematoma.

Conclusion: Intestinal hematoma is an unusual condition. Spontaneous small bowel hematomas most commonly involve the jejunum, followed by the ileum and duodenum. They occur in patients who receive excessive anticoagulation with phenprocoumon/warfarin or who have additional risk factors for bleeding. Diagnosis can be readily identified with sonography and confirmed with computed tomography. Early diagnosis is crucial because most patients can be treated successfully without surgery.