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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

SMALL BOWEL OBSTRUCTION DUE TO BOWEL WALL HEMATOMA


M Smith, MD, F Jamali, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Description


This clinical case reports the history of a patient seen for a small bowel obstruction due to a hematoma of the bowel wall. This complication occurred due to overdosage of anticoagulation. The treatment is usually conservative.

2. Keywords


Small bowel, obstruction, hematoma, anticoagulants

3. Patient


Female, 72-year-old

4. Past medical history


- insulin-dependent diabetes mellitus;
- asthma;
- cardiomyopathy;
- ejection fraction 35%;
- obesity, BMI= 45;
- no significant past surgical history;
- patient is anticoagulated because of cardiomyopathy.

5. History of present illness


Patient referred with a 36-hour history of crampy abdominal pain with lack of passage of flattus or fecal material.

6. Physical examination


- BP: 105/60;
- mild tenderness in suprapubic region but generally soft and non-tender;
- no peritoneal signs;
- high-pitched bowel sounds and mild abdominal distension.

7. Laboratory


- WBC: 10,9 x10*3 / mm3;
- Hct: 36.9 %;
- CRP: 187 (N<20);
- PTT:180 se (N=20-44);
- PT: 120 sec (N=10-16)INR: 20.

8. KUB


Few air fluid levels

9. CT scan


Focal thickening of the small bowel wall with target sign

10. Diagnosis


Small bowel obstruction due to spontaneous bowel hematoma probably due to over-anticoagulation.

11. Treatment


Intramural small bowel hematoma is best treated conservatively, since operative treatment is associated with a high complication rate and longer hospital stay. Conservative therapy involves correction of coagulation factors, NG decompression, correction of electrolyte imbalances and parenteral nutrition if indicated.

12. Discussion


Spontaneous intramural small bowel hemorrhage is a rare entity. It is almost always secondary to anticoagulant therapy. The diagnostic imaging modality of choice is the CT scan. Non-contrast CT seems superior to contrast CT in confirming the diagnosis. Therefore, patients who are clinically at risk for intramural small bowel hemorrhage should undergo a non-contrast CT can of the abdomen prior to the routine oral and intravenous contrast-enhanced scan. In most cases, the non-contrast scan will provide definitive diagnostic information, which may not be evident from the contrast-enhanced scan alone.

13. References


  1. Agresta F, Piazza A, Michelet I, et al. Small bowel obstruction: Laparoscopic approach. Surg Endosc 2000;14:154-6.
  2. Bass KN, Jones B, Bulkley GB. Current management of small bowel obstruction. Adv Surg 1997;31:1-34.
  3. Daneshmand S, Hedley CG, Stain SC. The utility and reliability of computed tomography scan in the diagnosis of small bowel obstruction. Am Surg 1999;65:922-6.
  4. Fevang BT, Jensen D, Fevang J, et al. Upper gastrointestinal contrast study in the management of small bowel obstruction - a prospective randomised study. Eur J Surg 2000;166:39-43.
  5. Joyce WP, Delaney PV, Gorey TF, et al. The value of water-soluble contrast radiology in the management of acute small bowel obstruction. Ann R Coll Surg Engl 1992;74:422-5.