Warfarin Woes: A Rare Case of Hemoperitoneum with Intramural Small Bowel Hematoma.

BACKGROUND Small bowel hematoma is a rare yet clinically significant condition characterized by the accumulation of blood within the mucosa and submucosa layers of the small intestine wall. It can lead to complications such as bowel obstruction, ischemia, perforation, and even hemorrhagic shock. The etiology of intramural small bowel hematoma is diverse, encompassing factors such as anticoagulant therapy, coagulopathies, vascular disorders, trauma, and underlying systemic conditions. CASE REPORT We present the case of a 67-year-old man with a history of aortic valve replacement who presented with intense abdominal pain. Physical examination revealed generalized abdominal tenderness and black stools upon rectal examination. Laboratory tests indicated coagulopathy with a prolonged thrombin time. A computed tomography scan confirmed the presence of an intramural small bowel hematoma and hemoperitoneum. The patient's condition significantly improved within 48 h under conservative management, including nasogastric tube insertion, continuous monitoring of gastric aspirate, nil per os status, intravenous fluids, and analgesics. Warfarin was temporarily stopped, and fresh frozen plasma was administered for anticoagulation reversal. Heparin infusion was initiated once the INR became within the therapeutic level. CONCLUSIONS The occurrence of spontaneous intramural small bowel hematoma, although rare, demands rapid diagnosis and prompt, well-coordinated management. This case underscores the pivotal role of multidisciplinary collaboration in providing a comprehensive assessment and a tailored approach to treatment. While conservative measures, including careful monitoring and supportive care, have demonstrated favorable outcomes, the consideration of surgical intervention remains crucial, particularly in severe cases.

[Hemocholecyst complicated by rupture of the gallbladder]. / Hémocholécyste compliquée d'une rupture de la vésicule biliaire.

Hemocholecyst is defined as a hemorrhage into the gallbladder. It is a rare complication of anticoagulant therapies which can progress to spontaneous rupture of the gallbladder with hemorrhagic shock. We report the case of a 75-year old hypertensive, dyslipidemic man with hypertensive heart disease initially hospitalized for left hemiplegia. The patient received antiplatelet and anticoagulant therapy with low molecular weight heparin (LMWH) as prevention strategy. After 5 days of treatment the patient developed hemocholecyst and hemoperitoneum, confirmed by angio-abdominal computerized tomography scan in emergency assessment. The patient underwent cholecystectomy, hemostasis of the gallbladder fossa and evacuation of the hemoperitoneum.

Spontaneous hemoperitoneum and anaphylactic shock associated with Hymenoptera envenomation in a dog.

OBJECTIVE: To describe the clinical presentation of a dog with spontaneous hemoperitoneum associated with anaphylactic shock from Hymenoptera envenomation. CASE SUMMARY: An 8-year-old female neutered Beagle presented as an emergency for acute onset of collapse, hematemesis, and hematochezia. The dog was tachycardic, tachypneic, and hypotensive. Initial assessment revealed a hemoperitoneum with documentation of a nonclotting sanguineous peritoneal effusion with PCV 81% and total protein concentration 65 g/L (6.5 g/dL). No obvious masses were appreciated ultrasonographically during original presentation and cytology of the peritoneal effusion was unremarkable. Peripheral PCV was 67% and total plasma protein concentration was 72 g/L (7.2 g/dL). A bee stinger was located in the right upper lip after presentation and was postulated to be the inciting trigger for the abdominal hemorrhage and shock. The patient was medically stabilized and ultimately made an uneventful recovery. Abdominal ultrasound performed 3 days after discharge revealed a single 0.85 cm hyperechoic liver nodule. Follow-up evaluation at 6 and 18 months after presentation documented a normal physical examination, unremarkable thoracic radiographs, and no change in the original hyperechoic liver nodule. NEW OR UNIQUE INFORMATION PROVIDED: This report details an unusual clinical presentation of anaphylactic shock due to Hymenoptera envenomation in a dog. To the authors' knowledge, spontaneous hemoperitoneum associated with anaphylaxis and bee envenomation has not been documented in the veterinary literature.

[Intraparietal hemorrhage of the small intestine related to hypocoagulation as an unusual cause of hemoperitoneum]. / Intraparietální hemoragie tenkého streva pri antikoagulacní terapii pacienta jako neobvyklá prícina hemoperitonea.

The authors present a case of acute abdomen, spontaneous hemoperitoneum, caused by intraparietal hemorrhage of the small intestine in a patient with hypocoagulation that was pharmacologically induced by warfarin anticoagulation therapy. Potential etiology of the described case is considered by the authors.

[Spontaneous hematoma of right angle of the transverse mesocolon: exceptional complication of anticoagulant therapy with vitamin K]. / Hématome spontané du méso de l'angle colique droit et du colon transverse compliquant un traitement par anti vitamine K: à propos d'un cas et revue de la littérature.

Spontaneous hematoma of transverse mesocolon is a rare complication of anticoagulant treatment with vitamin K. We report the case of spontaneous hematoma of right angle of the transverse mesocolon associated with a hemoperitoneum in a 32-year-old patient treated by fluindione for pulmonary embolism. The diagnosis must be made urgently. The abdominal ultrasound and the scanning confirm the diagnosis. It is important to note that surgery is indicated only in the case of complications such as the risk of rupture of the hematoma.

Hemoperitoneum Due to Warfarin Toxicity Presenting as Intestinal Obstruction.

The patients on anticoagulation therapy especially warfarin can develop gastrointestinal bleed, gum bleeding, hematuria or ecchymosis. Rarely do such patients present with hemoperitoneum producing symptoms. Hemoperitoneum can produce shock, cause compression symptoms or may even be fatal. Such patients can be managed conservatively or may need surgical exploration for ongoing bleeding or decompression. We had a patient taking warfarin who presented with hemoperitoneum producing intestinal symptoms. The patient was managed conservatively with fluid and blood product replacement and stopping warfarin. The benefits of thromboprophylaxis and the risks of bleeding should be carefully evaluated and the dose of warfarin carefully adjusted.

Cluster of cases of massive hemorrhage associated with anticoagulant detection in race horses.

Five horses originating from 4 different California race tracks were submitted to the California Animal Health and Food Safety Laboratory for necropsy and diagnostic workup. The 5 horses had a history of sudden collapse and death during exercise. In all of them, massive hemoperitoneum and hemorrhages in other cavities or organs were observed. The liver from these 5 animals and from 27 horses that had been euthanized due to catastrophic leg injuries (controls) were subjected to a rodenticide anticoagulant screen. Traces of brodifacoum, diphacinone, or bromadiolone were detected in the 5 horses with massive bleeding (5/5), and no traces of rodenticides were detected in control horses (0/27). Other frequent causes of massive hemorrhages in horses were ruled out in 4 of the cases; one of the horses had a pelvic fracture. Although only traces of anticoagulants were found in the livers of these horses and the role of these substances in the massive bleeding remains uncertain, it is speculated that exercise-related increases in blood pressure may have reduced the threshold for toxicity of these anticoagulants.

Spontaneous splenic rupture in infectious mononucleosis: case report and review of the literature.

A 15-year-old previously healthy girl presented in full arrest after 1 week of flu-like symptoms, recent diagnosis of infectious mononucleosis, and 1 day of abdominal pain. There was no history of trauma. Focused assessment with sonography for trauma examination showed free fluid in the abdomen. The patient died despite aggressive resuscitative management and emergency laparotomy with splenectomy, which showed grade V splenic laceration. Infectious mononucleosis is a common viral illness of adolescence. Spontaneous splenic rupture is a rare but potentially fatal complication. Anticipatory guidance about the importance of seeking medical care if abdominal pain develops during infectious mononucleosis is crucial to early diagnosis and intervention in the case of rupture. We discuss the current literature surrounding the outpatient follow-up of splenomegaly associated with infectious mononucleosis, as well as current practice and treatment options when rupture occurs.

Superwarfarin intoxication of unknown etiology accompanying hemoperitoneum in a patient on fluconazole therapy.

We report a case of brodifacoum (superwarfarin) intoxication of unknown etiology presenting as hemoperitoneum after fluconazole administration for one week before the onset of symptoms. The initial prothrombin time (PT) and partial thromboplastin time (PTT) were markedly prolonged, although a mixing study with normal plasma showed that the corrected PT and PTT were in the normal range. Vitamin K-dependent coagulation factors (Factors II (5%), VII (8%), IX (4%), and X (6%)), and Protein C (16%) and Protein S (19%) activities were reduced. Although the patient denied ingesting rodenticides or medications other than an antifungal drug, fluconazole, superwarfarin toxicity was suspected; subsequently, his serum brodifacoum level was found to be positive. After administration of fresh frozen plasma (FFP) and oral vitamin K(1) for five days and following drainage of the hemoperitoneum, the patient's bleeding tendency stopped, with slow decreases in PT and PTT. Compared to previous reports of superwarfarin intoxication of unknown exposure, this case is distinct in that the severe bleeding tendency needed surgical management and involved a suspected drug interaction with fluconazole. Therefore, superwarfarin intoxication should be suspected in subjects with markedly prolonged PT and PTT of unknown etiology, since a drug interaction could amplify the toxicity from a small exposure to superwarfarin.

[Reversal of acenocoumarol anticoagulation with activated factor VII in massive hemorrhage following rupture of a splenic artery pseudoaneurysm]. / Reversión del efecto del acenocumarol con factor VII activado en la hemorragia masiva tras rotura de aneurisma esplénico.

A 66-year-old man with a metallic valve and under treatment with acenocoumarol developed hypovolemic shock after rupture of a splenic artery pseudoaneurysm. We managed to reverse anticoagulation within 60 minutes by administering 20 mg of vitamin K and 4.8 mg of activated recombinant factor VII. No thromboembolic adverse events were observed. We discuss the pharmacologic effects of coumarin derivatives and their antagonists, as well as the use of activated factor VII in the reversal of anticoagulation by these drugs.

Reversión del efecto del acenocumarol con factor VII activado en la hemorragia masiva tras rotura de aneurisma esplénico / Reversal of acenocoumarol anticoagulation with activated factor VII in massive hemorrhage following rupture of a splenic artery pseudoaneurysm

Varón de 66 años, con prótesis valvular aórtica metálicaen tratamiento con acenocumarol, que sufrió unarotura de pseudoaneurisma de la arteria esplénica y posteriormentechoque hipovolémico. Se administró 20 mgde vitamina K y 4,8 mg de factor VII activado recombinantelográndose la reversión de la anticoagulación en60 min, sin efectos adversos tromboembólicos clínicamenteevidentes. Analizamos los aspectos farmacológicosde los cumarínicos y sus antagonistas, así como la experienciaexistente en el uso del factor VII activado en lareversión de la anticoagulación por estos fármacos(AU)

A 66-year-old man with a metallic valve and undertreatment with acenocoumarol developed hypovolemicshock after rupture of a splenic artery pseudoaneurysm.We managed to reverse anticoagulation within 60 minutesby administering 20 mg of vitamin K and 4.8 mg ofactivated recombinant factor VII. No thromboembolicadverse events were observed. We discuss the pharmacologiceffects of coumarin derivatives and their antagonists,as well as the use of activated factor VII in thereversal of anticoagulation by these drugs(AU)

[Two cases of primary unresectable and/or recurrent gastrointestinal stromal tumors of small intestine presenting hemoperitoneum caused by administration of imatinib mesylate].

Case1 was a 52-year-old man who had recurrence of postoperative intra-abdominal disseminations from gastrointestinal stromal tumor (GIST) of the jejunum. Case2 was a 66-year-old man who had GIST of the jejunum with multiple liver metastases. Two cases presented hemoperitoneum caused by administration of imatinib mesylate, and we conducted emergent surgery. In spite of surgically non-curative cases, it is suggested that the surgical management for GIST of high grade group with peritoneal exposure should be followed by the administration of imatinib mesylate.

[Spontaneous intestinal hematoma as anticoagulant treatment complication]. / Ematoma intestinale spontaneo come complicanza del trattamento anticoagulante.

The haemoperitoneum and bowel haematoma are complications of the oral anticoagulant treatment. The abdominal pain in patient under oral anticoagulant drugs represents a diagnostic problem; apart of the acute abdomen, we also have to consider unusual haemorrhagic lesion, rare in patients without coagulation problems. The early diagnosis of the complication in the patients permits a conservative treatment with excellent prognosis, instead of performing surgical operations in subjects with frequent comorbidities. We report a case of haemoperitoneum and intramural bowel haematoma in a patient with altered laboratory parameters and haemodynamic instability that required an urgent surgical procedure.