Abstract: Objective:To investigate the imaging characteristics of nontraumatic spontaneous intramural hematoma of small bowel secondary to warfarin therapy.
Methods:The retrospective and descriptive study was conducted. The clinical data of 12 patients with nontraumatic spontaneous intramural hematoma of small bowel secondary to warfarin therapy who were admitted to the First People′s Hospital of Wenling (11 patients) and Taizhou Hospital of Zhejiang Province (1 patient) between January 2010 and December 2016 were collected. Patients received plain and enhanced scans of computed tomography (CT). Patients stopped warfarin therapy, received intramuscular injection of vitamin K1 and fresh-frozen plasma transfusion. Observation indicators: (1) primary signs of CT: ① small bowel wall thickening; ② increased density of small bowel wall; (2) secondary signs of CT: intestine lumen stenosis, intestinal pneumatosis, perienteric changes and other concomitant signs;(3) treatment situations. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range).
Results:Twelve patients received total abdomen plain scans of CT, and 7 received total abdomen enhanced scans of CT. (1) Primary signs of CT: ① Small bowel wall thickening. CT of 12 patients showed solitary, homogeneously symmetric, consecutive and diffuse thickening of small bowel wall, including ileal involvement in 7 patients and jejunum involvement in 5 patients. Ascending part of duodenum of 3 patients involved the 2nd and 3rd groups small bowel. The average length of involved small bowel was 30.7 cm (range, 11.0-58.0 cm). There was no multifocal thickening or colonic involvement. Of 12 patients, 10 and 2 showed moderate thickening (thickness was 1.0-2.0 cm) and severe thickening (thickness > 2.0 cm), and the thickest small bowel wall was 2.5 cm. ② Increased density of small bowel wall. Twelve patients showed varying degrees of increased density of small bowel wall, with an average value of 49.7 HU (range, 36.0-63.4 HU). Of 12 patients, homogeneously increased whole layer density of small bowel wall were detected in 4 patients, higher submucous layer density of small bowel compared with serosal layer density in 4 patients, and all of the above characteristics in 4 patients. Enhanced scans of CT in 7 patients showed enhancement in small bowel mucosal layer and serosal layer, no obvious enhancement in the submucous layer of small bowel wall, clear layers, and a target sign when small bowel lumen was perpendicular to scan slice, including 5 patients with obvious enhancement in small bowel mucosal layer, spring-like change, and clear imaging in portal vein phase. (2) Secondary signs of CT: ① Intestine lumen stenosis: 12 patients had varying degrees of intestine lumen stenosis. Five patients were complicated with small bowel obstruction, showing a gas-liquid level. ② Intestinal pneumatosis: 2 of 12 patients showed patchy and mottled gas shadow. ③ Perienteric changes and other concomitant signs: 12 patients showed obviously increased fat density in surrounding area of involved small bowel and corresponding mesenteric area, and indistinct outside small bowel, including 8 with lots of lath-like high density shadow in surrounding area of small bowel and mesenteric area. The varying degrees of hemoperitoneum were seen in 12 patients. (3) Treatment situations: of 12 patients, 9 underwent correct treatments, 8 of them were improved, and 1 of them with persistently severe abdominal pain underwent urgent explorative laparotomy, showing hemorrhage and necrosis, and then underwent surgery; 3 didn′t undergo correct treatment, without improved or severe symptoms.
Conclusions:Patients undergoing anticoagulant therapy show acute abdominal pain with abnormal coagulation function, small bowel wall thickening and increased density by CT scans, hemoperitoneum complicated with intestine lumen stenosis, small bowel obstruction and hematocele in surrounding area of small bowel and mesenteric area, these are highly indicative of nontraumatic spontaneous intramural hematoma of small bowel secondary to warfarin therapy.