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Unusual Cause of Abdominal Pain
CLINICAL CHALLENGES AND IMAGES IN GI Grace Elta and Robert J. Fontana, Section Editors
Unusual Cause of Abdominal Pain Q3
Lisa Wu1 and Hsu-Heng Yen1,2 1 Department of Gastroenterology, Changhua Christian Hospital, 2General Education Center, Chienkuo Technology University Changhua, Changhua, Taiwan
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Question: A 77-year-old man with atrial fibrillation presented to the emergency department with abdominal pain that had worsened over the course of 1 day. The patient had suffered a similar attack 6 months earlier and was diagnosed with mesenteric ischemia. He had received anticoagulant therapy since this first attack. Physical examination revealed mild pale conjunctiva, hypoactive bowel sounds, and mild muscle guarding over the lower abdomen without bleeding. Laboratory analysis revealed normal liver and renal function. The white blood cell count was well within the normal range, and the patient had mild anemia (hemoglobin, 10.2 g/dL). A bedside abdominal ultrasound was performed (Figure A, Video 1). Further assessment of the coagulation profile revealed a prothrombin time of >160 s (normal, 9.9–12). An abdominal computed tomography examination was subsequently performed (Figure B). What is the finding of abdominal ultrasound? What is the finding of abdominal computed tomography? Look on page 000 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.
Q1
Conflicts of interest The authors disclose no conflicts. © 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.01.009
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CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 4: Spontaneous Intramural Hematoma of the Small Intestine
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The abdominal ultrasound revealed small intestinal wall thickening with little ascites (Figure A). The microvascular ultrasound imaging revealed preserved blood flow of the intestinal wall (Video 1). The abdominal computed tomography examinations revealed an intact mesenteric vasculature and long segmental small bowel wall thickening up to 2 cm, which was suggestive of intramural hematoma (Figure B). The patient was admitted, bleeding tendency was corrected, and parenteral nutrition was provided. The abdominal pain improved gradually over the course of 5 days. The endoscopy revealed swelling of the jejunum with patchy ecchymosis (Figure C, Video 2) and endoscopic ultrasound revealed resolution of the submucosal hemorrhage (Figure D). The patient was put on an oral diet on day 7 and discharged on day 11.The patient was admitted with correction of the coagulopathy. Acute abdominal pain in patients with atrial fibrillation poses a diagnostic challenge as compared with that in patients with normal cardiac rhythm in the emergency department.1,2 Spontaneous bleeding from the intestinal wall is rare and usually occurs in patients with a bleeding tendency, such as those with hemophilia or undergoing anticoagulant therapy, and is sometimes referred to as “anticoagulant ileus.”2 The triad of warfarin overdose, circumferential thickening of the small intestine, and intestinal obstruction is characteristic of spontaneous intramural hematoma.2 Abdominal computed tomography scan may reveal long symmetric bowel wall thickening with hyperdense material, sometimes referred to as “stack-of-coins,” “pseudo-kidney,” or “coiled spring” signs.2 Treatment is usually conservative with correction of the coagulopathy.
Supplementary Material Note: To access the supplementary material accompanying this article, visit the online version of Gastroenterology at www. gastrojournal.org, and at http://dx.doi.org/10.1053/j.gastro.2016.01.009.
References 1. 2. 3. Q2
Barajas RF Jr, Yeh BM, Webb EM, et al. Spectrum of CT findings in patients with atrial fibrillation and nontraumatic acute abdomen. AJR Am J Roentgenol 2009;193:485–492. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel hematoma: imaging findings and outcome. AJR Am J Roentgenol 2002;179:1389–1394. Rauh P, Uhle C, Ensberg D, et al. Sonographic characteristics of intramural bowel hematoma. J Clin Ultrasound 2008; 36:367–368.
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).
2 DIS 5.4.0 DTD YGAST60236 proof 27 February 2016 1:30 am ce
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Unusual Cause of Abdominal Pain Q3
Lisa Wu1 and Hsu-Heng Yen1,2 1 Department of Gastroenterology, Changhua Christian Hospital, 2General Education Center, Chienkuo Technology University Changhua, Changhua, Taiwan
print & web 4C/FPO
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
Question: A 77-year-old man with atrial fibrillation presented to the emergency department with abdominal pain that had worsened over the course of 1 day. The patient had suffered a similar attack 6 months earlier and was diagnosed with mesenteric ischemia. He had received anticoagulant therapy since this first attack. Physical examination revealed mild pale conjunctiva, hypoactive bowel sounds, and mild muscle guarding over the lower abdomen without bleeding. Laboratory analysis revealed normal liver and renal function. The white blood cell count was well within the normal range, and the patient had mild anemia (hemoglobin, 10.2 g/dL). A bedside abdominal ultrasound was performed (Figure A, Video 1). Further assessment of the coagulation profile revealed a prothrombin time of >160 s (normal, 9.9–12). An abdominal computed tomography examination was subsequently performed (Figure B). What is the finding of abdominal ultrasound? What is the finding of abdominal computed tomography? Look on page 000 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.
Q1
Conflicts of interest The authors disclose no conflicts. © 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.01.009
Gastroenterology 2016;-:1–2 DIS 5.4.0 DTD YGAST60236 proof 27 February 2016 1:30 am ce
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 4: Spontaneous Intramural Hematoma of the Small Intestine
print & web 4C/FPO
117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
The abdominal ultrasound revealed small intestinal wall thickening with little ascites (Figure A). The microvascular ultrasound imaging revealed preserved blood flow of the intestinal wall (Video 1). The abdominal computed tomography examinations revealed an intact mesenteric vasculature and long segmental small bowel wall thickening up to 2 cm, which was suggestive of intramural hematoma (Figure B). The patient was admitted, bleeding tendency was corrected, and parenteral nutrition was provided. The abdominal pain improved gradually over the course of 5 days. The endoscopy revealed swelling of the jejunum with patchy ecchymosis (Figure C, Video 2) and endoscopic ultrasound revealed resolution of the submucosal hemorrhage (Figure D). The patient was put on an oral diet on day 7 and discharged on day 11.The patient was admitted with correction of the coagulopathy. Acute abdominal pain in patients with atrial fibrillation poses a diagnostic challenge as compared with that in patients with normal cardiac rhythm in the emergency department.1,2 Spontaneous bleeding from the intestinal wall is rare and usually occurs in patients with a bleeding tendency, such as those with hemophilia or undergoing anticoagulant therapy, and is sometimes referred to as “anticoagulant ileus.”2 The triad of warfarin overdose, circumferential thickening of the small intestine, and intestinal obstruction is characteristic of spontaneous intramural hematoma.2 Abdominal computed tomography scan may reveal long symmetric bowel wall thickening with hyperdense material, sometimes referred to as “stack-of-coins,” “pseudo-kidney,” or “coiled spring” signs.2 Treatment is usually conservative with correction of the coagulopathy.
Supplementary Material Note: To access the supplementary material accompanying this article, visit the online version of Gastroenterology at www. gastrojournal.org, and at http://dx.doi.org/10.1053/j.gastro.2016.01.009.
References 1. 2. 3. Q2
Barajas RF Jr, Yeh BM, Webb EM, et al. Spectrum of CT findings in patients with atrial fibrillation and nontraumatic acute abdomen. AJR Am J Roentgenol 2009;193:485–492. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel hematoma: imaging findings and outcome. AJR Am J Roentgenol 2002;179:1389–1394. Rauh P, Uhle C, Ensberg D, et al. Sonographic characteristics of intramural bowel hematoma. J Clin Ultrasound 2008; 36:367–368.
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).
2 DIS 5.4.0 DTD YGAST60236 proof 27 February 2016 1:30 am ce
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