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.

The Diagnostic Value of Brain CT Scans in Evaluating Dizziness in the Emergency Department: A Retrospective Study.

BACKGROUND: Dizziness is a common presenting complaint to emergency departments (ED) worldwide, with causes ranging from benign to life-threatening incidents. Computerized tomography (CT) of the brain remains a common diagnostic tool used by emergency physicians; however, it appears to be of low diagnostic value, especially in patients with normal neurological assessment while carrying multiple negative implications on both the patients and the healthcare systems. Our study aims to evaluate the diagnostic value of brain CT scans in assessing patients presenting to the ED with acute dizziness. MATERIALS AND METHODS: Retrospective review of medical records of patients presenting with complaints of dizziness to the ED at Salmaniya Medical Complex (SMC) who underwent a brain CT scan from January to June 2023. Collected data included patients' demographic information, presenting complaints, and CT scan results. A multivariable analysis of factors associated with positive CT scans was performed. RESULTS: A total of 481 participants were enrolled in the study, representing diverse age groups as follows: 18-30 years (12.3%), 31-40 years (15.8%), 41-50 years (17.7%), 51-60 years (22.0%), and those aged over 60 years (32.2%). Among the participants, 56.3% identified as male and 43.7% as female. In terms of head trauma history, 7.1% of participants reported such incidents, while the majority (92.9%) had no history of head trauma. Exploring comorbidities, 43.5% of participants had at least one associated medical condition. Among the 481 study participants, brain CT scans revealed that the majority (93.1%) exhibited unremarkable results. The remaining cases exhibited acute events, including 5.4% with infarcts, 1.1% with hemorrhages, and 0.4% with space-occupying lesions. CONCLUSION: This study provides evidence of the limited value of brain CT scans in dizzy patients with unremarkable clinical examinations. As for clinicians, it can serve as a steppingstone toward the formulation of a policy and a set of guidelines for requesting brain CT scans in patients presenting to the ED with dizziness. Future studies are suggested to provide more insights into the cost-effectiveness and utility of head CT scans in providing valuable findings.

Herlyn-Werner-Wunderlich Syndrome: A Rare Case Report.

Müllerian anomalies are a complex spectrum of congenital defects of the female reproductive tract caused by an interruption in the normal development of Müllerian ducts and their associated structures. The clinical presentation of these anomalies varies and includes acute presentations. In this report, a case of a 16-year-old girl who attended the emergency department with severe colicky abdominal pain and nausea has been presented. The patient was on the fifth day of the menstrual cycle, and her pain was not completely relieved by the administration of non-steroidal anti-inflammatory drugs. The patient had menarche at the age of 14 years and used to have a regular menstrual cycle every 30 days. Her menstrual flow was average with a cycle duration of five days. An abdominal ultrasound examination was performed to rule out ovarian torsion, which demonstrated normal appearance and ovary size, and a large heterogeneous collection in the rectouterine pouch with unclear uterine morphology. Subsequently, magnetic resonance imaging revealed a duplication of the uterus, cervix, and vagina. The right hemivagina and right endometrial cavity were distended, consistent with hematometrocolpos. Right renal agenesis with compensatory hypertrophy of the left kidney was observed. The constellation of uterus didelphys obstructed hemivagina, and ipsilateral renal agenesis represented the diagnosis of Herlyn-Werner-Wunderlich syndrome. Herlyn-Werner-Wunderlich syndrome is a rare and complex type of congenital uterine abnormality. Although rare, this syndrome should be considered in the differential diagnosis of severe dysmenorrhea in adolescent girls with renal anomalies. In this case, the patient underwent vaginoplasty with resection of the vaginal septum to relieve the obstruction. At follow-up visits, she did not have a recurrence of symptoms.