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An Unusual Cause of Small Bowel Obstruction
CLINICAL CHALLENGES AND IMAGES IN GI An Unusual Cause of Small Bowel Obstruction Jackson J. Liang1 and Phil A. Hart2 1
Department of Internal Medicine, and 2Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Minnesota
Question: A 42year-old man presented with nausea, vomiting, abdominal pain, and distention over the previous 4 days. His past medical history was significant for 2 episodes of unprovoked pulmonary embolism 6 and 4 years before admission. Despite recommendations for lifelong anticoagulation, he discontinued taking the medication <12 months after each episode, and had not taken any anticoagulation preceding the current presentation. Otherwise, he did not take any prescription or over-the-counter medications or supplements. Abdominal examination revealed distention and epigastric tenderness with mild rebound tenderness. International normalized ratio was >15.0 and partial thromboplastin time was 90 seconds (normal, 26–36). Prothrombin and partial thromboplastin times corrected with mixing studies ruling out the presence of circulating inhibitors. Factor activity levels for factors II, VII, IX, and X (15%, 3%, 11%, and 13%, respectively) were very low. Computed tomography (CT) of the abdomen with contrast was performed (Figure A). He also underwent upper endoscopy, which demonstrated circumferential edema and biopsies were obtained for histopathologic examination (Figure B; H&E stain; low-power original magnification). What is the most likely diagnosis? Look on page 286 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Acknowledgments The authors acknowledge Thomas C. Smyrk, MD (Department of Pathology), for his assistance with the histopathology.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.03.040
Gastroenterology 2014;147:285–286
CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 3 (page 285): Small Bowel Intramural Hematoma Abdominal CT (Figure A) demonstrated bowel wall thickening in the distal duodenum extending to the proximal jejunum, and a small amount of hyperintense free fluid seen in the paracolic gutters and pelvis, consistent with hemorrhagic ascites. Tissue biopsy of the duodenum (Figure B) demonstrates mucosal hemorrhage with surrounding hyalinization and increase in inflammatory cells, consistent with the diagnosis of spontaneous small bowel intramural hematoma (SBIH). SBIH is an infrequent cause of small bowel obstruction that generally results from blunt abdominal trauma. Nontraumatic SBIH most commonly occurs in the setting of warfarin toxicity. Patients present with abdominal pain, obstruction, or intraluminal bleeding (hematemesis or melena).1 Abdominal CT with contrast is generally diagnostic. Classic CT findings include circumferential wall thickening, intramural hyperdensity, luminal narrowing, and intestinal obstruction.2 Upper endoscopy is generally unnecessary. Serum warfarin level was negative, but an anticoagulant poisoning panel revealed detectable levels of brodifacoum. Brodifacoum is a rodenticide that is considered a “superwarfarin” and is different from warfarin in that overdose is resistant to reversal with standard doses of vitamin K. The anticoagulant effects can last for weeks to months despite drug discontinuation. Superwarfarin poisoning should be considered in all patients with coagulopathy of vitamin K-dependent factors that resolves with mixing and in the absence of warfarin exposure.3 He was treated conservatively with bowel rest and his coagulopathy was reversed with fresh frozen plasma and intravenous vitamin K until he could tolerate oral medications. The small bowel obstruction resolved with 72 hours of conservative management and he was transitioned to oral vitamin K. He denied knowingly ingesting brodifacoum, although he did acknowledge handing the rodenticide. Because this agent has a foul taste and large amounts of consumption are required for detection in the blood, a factitious disorder was suspected. Despite evaluation by our psychiatry team, he did not reveal a motive.
References 1. 2. 3.
Veldt BJ, Haringsma J, Florijn KW, et al. Coumarin-induced intramural hematoma of the duodenum: case report and review of the literature. Scand J Gastroenterol 2011;46:376–379. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel hematoma: imaging findings and outcome. AJR Am J Roentgenol 2002;179:1389–1394. Chua JD, Friedenberg WR. Superwarfarin poisoning. Arch Intern Med 1998;158:1929–1932.
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).
286
Department of Internal Medicine, and 2Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Minnesota
Question: A 42year-old man presented with nausea, vomiting, abdominal pain, and distention over the previous 4 days. His past medical history was significant for 2 episodes of unprovoked pulmonary embolism 6 and 4 years before admission. Despite recommendations for lifelong anticoagulation, he discontinued taking the medication <12 months after each episode, and had not taken any anticoagulation preceding the current presentation. Otherwise, he did not take any prescription or over-the-counter medications or supplements. Abdominal examination revealed distention and epigastric tenderness with mild rebound tenderness. International normalized ratio was >15.0 and partial thromboplastin time was 90 seconds (normal, 26–36). Prothrombin and partial thromboplastin times corrected with mixing studies ruling out the presence of circulating inhibitors. Factor activity levels for factors II, VII, IX, and X (15%, 3%, 11%, and 13%, respectively) were very low. Computed tomography (CT) of the abdomen with contrast was performed (Figure A). He also underwent upper endoscopy, which demonstrated circumferential edema and biopsies were obtained for histopathologic examination (Figure B; H&E stain; low-power original magnification). What is the most likely diagnosis? Look on page 286 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Acknowledgments The authors acknowledge Thomas C. Smyrk, MD (Department of Pathology), for his assistance with the histopathology.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.03.040
Gastroenterology 2014;147:285–286
CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 3 (page 285): Small Bowel Intramural Hematoma Abdominal CT (Figure A) demonstrated bowel wall thickening in the distal duodenum extending to the proximal jejunum, and a small amount of hyperintense free fluid seen in the paracolic gutters and pelvis, consistent with hemorrhagic ascites. Tissue biopsy of the duodenum (Figure B) demonstrates mucosal hemorrhage with surrounding hyalinization and increase in inflammatory cells, consistent with the diagnosis of spontaneous small bowel intramural hematoma (SBIH). SBIH is an infrequent cause of small bowel obstruction that generally results from blunt abdominal trauma. Nontraumatic SBIH most commonly occurs in the setting of warfarin toxicity. Patients present with abdominal pain, obstruction, or intraluminal bleeding (hematemesis or melena).1 Abdominal CT with contrast is generally diagnostic. Classic CT findings include circumferential wall thickening, intramural hyperdensity, luminal narrowing, and intestinal obstruction.2 Upper endoscopy is generally unnecessary. Serum warfarin level was negative, but an anticoagulant poisoning panel revealed detectable levels of brodifacoum. Brodifacoum is a rodenticide that is considered a “superwarfarin” and is different from warfarin in that overdose is resistant to reversal with standard doses of vitamin K. The anticoagulant effects can last for weeks to months despite drug discontinuation. Superwarfarin poisoning should be considered in all patients with coagulopathy of vitamin K-dependent factors that resolves with mixing and in the absence of warfarin exposure.3 He was treated conservatively with bowel rest and his coagulopathy was reversed with fresh frozen plasma and intravenous vitamin K until he could tolerate oral medications. The small bowel obstruction resolved with 72 hours of conservative management and he was transitioned to oral vitamin K. He denied knowingly ingesting brodifacoum, although he did acknowledge handing the rodenticide. Because this agent has a foul taste and large amounts of consumption are required for detection in the blood, a factitious disorder was suspected. Despite evaluation by our psychiatry team, he did not reveal a motive.
References 1. 2. 3.
Veldt BJ, Haringsma J, Florijn KW, et al. Coumarin-induced intramural hematoma of the duodenum: case report and review of the literature. Scand J Gastroenterol 2011;46:376–379. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel hematoma: imaging findings and outcome. AJR Am J Roentgenol 2002;179:1389–1394. Chua JD, Friedenberg WR. Superwarfarin poisoning. Arch Intern Med 1998;158:1929–1932.
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).
286