Reactions 1680, p340 - 2 Dec 2017
Gastric intramural haematoma: 3 case reports
In a retrospective review, three men aged 40 years, 62 years
and 65 years were described, who developed gastric
intramural haematoma during treatment with warfarin [routes,
dosages and durations of treatments to reactions onsets not
stated; not all indications and outcomes stated].
Case 1: A 40-year-old man, presented to an emergency
department with complaints of abdominal pain and vomiting.
The man had an extensive history of cardiac problems, and had
been taking warfarin. His abdominal exam showed that his
upper abdomen was tender and rigid. There were no palpable
masses or bowel sounds. Minor bleeding from the gums was
observed. He was admitted, and his laboratory workup
revealed mild anaemia, leucocytosis and an INR of 17. An
18mm thickened hypoechoic gastric wall was observed on the
abdominal ultrasound. An endoscopy was carried out, which
showed sub-mucosal haemorrhage which involved the antrum
and body of the stomach, extending upto the duodenum.
There were no signs of active bleeding. A CT scan of the
abdomen confirmed a haematoma. He was initiated on stat
vitamin-K and fresh frozen plasma. He was admitted for
13 days for observation and correction of the coagulation
deficits. His stomach thickness reduced after five days of
admission. Another endoscopy 10 days later showed
significant improvements of the mucosal appearance.
Case 2: A 62-year-old man presented to the emergency
centre with complaints of abdominal pain and constipation
lasting for two days. He had a history of ischaemic heart
disease and atrial fibrillation, and hence, he had been
administering warfarin. His abdomen appeared distended with
tenderness and hypoactive bowel sounds. Melena was
observed upon rectal examinations. Abdominal ultrasound
showed significant thickening of small bowel loops and a left
renal cyst. An abdominal CT was conducted with intravenous
contrast, which showed thickening of the proximal 20cm of
jejunum with patent superior mesenteric artery and vein. His
INR value was 10.5, whereas the rest of the laboratory tests
were normal. A gastric intramural haematoma was suspected.
He was treated with vitamin-K, and his pain improved and
fresh frozen plasma. He was discharged after four days. His
dose of oral anticoagulation was adjusted.
Case 3: A 65-year-old man presented to the emergency
centre with complains of abdominal pain. He had a history of
ischaemic heart disease, and had been administering warfarin.
He described his pain to be of a diffuse, dull and aching type
with tenderness in the right iliac fossa. Examination showed
tenderness on the right lower quadrant. His laboratory
examinations showed high blood sugar levels and an INR 9. An
abdominal ultrasound was inconclusive, however, a 10 cm
thickened terminal ileal loop was observed on the CT. A gastric
intramural haematoma was suspected. He was treated with
vitamin-K, fresh frozen plasma and fluid resuscitation. By the
second admission day, his symptoms resolved.
Author comment: "Gastric mural hematomas are very rare
complications of anticoagulant therapy and present mainly
with upper abdominal pain and vomiting that may or may
not be blood stained."
Bekheit M, et al. Non-traumatic intramural hematomas in patients on anticoagulant
therapy: Report of three cases and overview of the literature. African Journal for
Emergency Medicine 4: e1-e4, No. 4, Dec 2014. Available from: URL: http://
doi.org/10.1016/j.afjem.2014.07.009 - Egypt
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