Spontaneous intramural small-bowel hematoma secondary to coagulopathy in patients receiving vitamin K antagonists: A case series report

RATIONALE: Spontaneous intramural small-bowel hematoma (SISBH) is a rare but potentially life-threatening complication of anticoagulant therapy and severe coagulopathy. Because it may mimic acute abdomen or intestinal obstruction, delayed recognition can lead to unnecessary surgery. This study aimed to describe the clinical characteristics, imaging findings, and outcomes of patients with SISBH secondary to vitamin K antagonist-related coagulopathy. PATIENT CONCERNS: We retrospectively analyzed 11 consecutive patients with SISBH secondary to vitamin K antagonist-related coagulopathy, including available follow-up data up to 3 months after treatment. The median age was 65 years, and 72.3% were male. All patients presented with acute abdominal pain. Abdominal distension occurred in 63.6%, vomiting in 45.5%, and gastrointestinal bleeding in 9.1%. DIAGNOSES: All patients had markedly abnormal coagulation profiles, with a median international normalized ratio (INR) of 8.5 and a median prothrombin activity of 8%. Contrast-enhanced computed tomography revealed circumferential bowel wall thickening with increased intramural attenuation and luminal narrowing in all cases. Partial intestinal obstruction was identified in 54.5%. INTERVENTIONS: Ten patients (90.9%) were treated conservatively with discontinuation of anticoagulants, intravenous vitamin K, and fresh frozen plasma. One patient underwent diagnostic laparoscopy without bowel resection. OUTCOMES: Coagulation parameters improved significantly after treatment (INR, P = .003). The median hospital stay was 6 days. No in-hospital mortality occurred. During the 3-month follow-up period, 1 patient experienced recurrence. LESSONS: Markedly elevated INR in patients with acute abdominal pain should raise suspicion for SISBH. Early computed tomography evaluation and timely correction of coagulopathy may facilitate conservative management and reduce the need for surgical exploration in selected cases.