Teaching Case

A patient with arrhythmia absoluta presented with diffuse abdominal pain, soft abdominal wall and no defence tension. There was leucocytosis and anaemia and the INR was 10. On abdominal plain film there was a large tumour in the left upper and middle abdomen. Abdominal CT showed an upper jejunal thickening and on ultrasound a cockade was seen.

The patient had a history of two myocardial infarctions, 21 and 22 years previous to presentation. He had been on phenprocoumon since tachyarrhythmia absoluta was diagnosed two years previously. On presentation he had diffuse abdominal pain, the abdominal wall was soft and there was no defence tension. The patient vomited once after a meal, but denied further nausea. He had been constipated for three days. There was no significant difference in axial and rectal temperatures. Initially, a leucocytosis of 17,620 leucocytes per µl was measured. The international ratio (INR) was 10 corresponding to a Quick of 5%. The haemoglobin was decreased to 10.9 g/dl. The patient medications were 3 mg phenprocoumon per day and verpamil, furosemide and digitoxine.

On ultrasound examination (Fig. 1) there was a hypoechoic cockade with a small rounded hyperechoic centre in the left upper abdomen close to the left kidney. This cockade was 4.9 cm in diameter horizontally and 3.9 cm vertically. Between the liver and the right kidney there was a small hypoechoic seam indicating free intraabdominal fluid.

The abdominal x-ray (Fig. 2) showed a large tumour in the left upper and middle abdomen similar to an enlargement of a jejunal loop.

On abdominal CT (Fig.4) the thickening of the jejunal wall was verified up to 1-2 cm positioning in the left upper and middle abdomen. The thickend jejunal wall was nearly isointense to the liver (50-60 HE in native CT) and showed no significant enhancement after iv injection of contrast medium. A small liquid seam surrounded the liver.

Laparoscopic examination (Fig. 3) showed a large haematoma of the wall of a monstrously thickened jejunal loop. Free intrabdominal blood between the abdominal wall and the mesenteric organs was also shown. In the same laparoscopic procedure a 20 French drain was put into the intraperitoneal cavity to drain free blood.

The postoperative course was uneventful. The patient was discharged after one week.

Bleeding in parts of the wall of the small bowel is a rare complication after overdosage of coumarin-derivatives. Intramural haematomas are mostly localised in the duodenal wall and are usually secondary to blunt abdominal trauma; they may occur after gastro-duodenoscopic biopsy (2). Sporadically an obstructive jaundice is described as a result of compression of the intramural parts of the ductus choledochus or the papilla of Vater (1). On CT or MR one may see an enlarged ductus choledochus or intrahepatic bile ducts. The wall of the small bowel is thickened and there is no significant contrast enhancement after i.v. injection of contrast medium in CT and MR.

Haemorrhage into the bowel demonstrates the same sign in MR as intramuscular haemorrhages elsewhere. Acute haematomas show aqueous material with a long T2 and an intermediate T1, corresponding to high protein content. Within days the T1 falls as haemoglobin is oxidised to methaemoglobin. After a few weeks, on T1-weighted images a bright ring arises at the periphery of the lesion. One may see a small rim of intensely hypointense material on T2 images, which corresponds to haemosiderin taken up in macrophages. This is described as the ring sign in duodenal haematoma (3).

On ultrasound, blood typically shows a hypoechoic signal. Thus, intramural haematomas are recognisable by a hypoechoic cockade as shown in Fig. 2. The hyperechoic centre is the intestine lumen with perhaps small amounts of air.

On abdominal plain film one can suspect an intramural haematoma in cases with thickened intestinal loops in combination with anaemia and clinical symptoms include constipation, nausea, vomiting, and abdominal pain.

CT or MR is necessary to prove the diagnosis. If laparoscopy is employed, a therapeutic drain can be applied to evacuate free intra-abdominal blood.

Conservative therapy is usually sufficient: reducing anticoagulation and substituting blood, blood products and electrolytes. Usually resection of the affected parts of the intestine is not necessary.

Avent et al. pointed out that nearly 100 cases have been reported of intramural haematoma of the small intestine induced by anticoagulant therapy. The sites most frequently involved are the duodenum and proximal jejunum. Most patients are white males about 60 years of age (5). In Medline most described intramural haematomas are localised in the duodenum. We found only one corresponding case with an intramural haematoma of a jejunal loop with simultaneous intraperitoneal haemorrhage (4). Thus a haematoma of the jejunum, as shown in this case, is extremely rare.