Clinical features and outcomes in spontaneous intramural small bowel hematoma: cohort study and literature review

Eun Ae Kang; Seung Jun Han; Jaeyoung Chun; Hyun Jung Lee; Hyunsoo Chung; Jong Pil Im; Sang Gyun Kim; Joo Sung Kim; Hyuk Yoon; Cheol Min Shin; Young Soo Park; Nayoung Kim; Dong Ho Lee; Hyun Chae Jung

doi:10.5217/ir.2018.00085

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Original Article Clinical features and outcomes in spontaneous intramural small bowel hematoma: cohort study and literature review: Eun Ae Kang^1,*, Seung Jun Han^1,*, Jaeyoung Chun^1,, Hyun Jung Lee¹, Hyunsoo Chung¹, Jong Pil Im¹, Sang Gyun Kim¹, Joo Sung Kim¹, Hyuk Yoon², Cheol Min Shin², Young Soo Park², Nayoung Kim², Dong Ho Lee², Hyun Chae Jung¹; Intestinal Research 2019;17(1):135-143.
DOI: https://doi.org/10.5217/ir.2018.00085
Published online: October 10, 2018

¹Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea

²Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea

Correspondence to Jaeyoung Chun, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 03080, Korea. Tel: +82-2-740-8112, Fax: +82-2-743-6701, E-mail: j40479@snu.ac.kr

*These authors contributed equally to this study.

• Received: June 1, 2018 • Revised: July 5, 2018 • Accepted: July 10, 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
NOTES
Supplementary Materials
REFERENCES

Abstract

Background/Aims
Spontaneous intramural small bowel hematoma (SISBH) is an extremely rare complication of anticoagulant or antiplatelet therapy. We assessed the clinical characteristics and outcomes of patients with SISBH according to the anatomical location of the hematoma.
Methods
From January 2003 to February 2016, medical records for all patients hospitalized for SISBH at 2 tertiary referral hospitals were retrospectively reviewed. The primary outcome was requirement for surgery.
Results
A total of 37 patients were enrolled. The mean age was 74.1 years. Among them, 33 patients (89.2%) were taking anticoagulant and/or antiplatelet agents. Duodenal intramural hematoma was detected in 4 patients (10.8%), jejunal in 16 (43.2%), and ileal in 17 (45.9%). Compared to jejunal and ileal involvement, duodenal intramural hematoma was significantly associated with high Charlson comorbidity index and low levels of white blood cells, hemoglobin, and platelets in the blood. SISBH in the duodenum was related to thrombocytopenia in 3 patients following systemic chemotherapy for malignancy. All patients with SISBH showed clinical improvement with conservative therapy. Mean length of hospital stay was 9.35 days. Independent predictors of a hospital stay of more than 7 days were body weight less than 60 kg (odds ratio [OR], 12.213; 95% confidence interval [CI], 1.755–84.998; P=0.011) and a history of cerebrovascular accidents (OR, 6.667; 95% CI, 1.121–39.650; P=0.037).
Conclusions
Compared to jejunal and ileal involvement, thrombocytopenia may result in spontaneous duodenal intramural hematoma among patients who are treated with systemic chemotherapy for malignancies. Patients with SISBH have excellent clinical outcomes with conservative therapy regardless of the anatomical location of the hematoma.
Keywords: Hematoma; Intestine, small; Treatment outcome

INTRODUCTION

Spontaneous intramural small bowel hematoma (SISBH) was initially described in 1838 [1], and has been often reported since the 1960s [2-4]. It is an extremely rare disease, with a reported incidence of 1 case per 2,500 patients receiving anticoagulant therapy per year in a retrospective epidemiologic survey [5]. The jejunum is the most commonly involved part of the small intestine followed by the ileum and duodenum [6,7]. The etiologic and clinical characteristics of SISBH based on the location of SISBH still remains unclear.

Anticoagulant or antiplatelet therapy is a risk factor for SISBH. Warfarin use was associated with most cases of SISBH [2-4,6-28] and heparin, low molecular weight heparin (LMWH), and aspirin can also induce SISBH [8,29-33]. The complications of SISBH such as intestinal obstruction, intestinal infarction, and pancreatitis with obstructive jaundice may require surgical interventions for clinical improvement [6,8,10,14,18,27-31,34]. However, the clinical prognosis of SISBH has not been fully determined due to its extremely low incidence. The aim of this study was to assess the clinical characteristics and outcomes of patients with SISBH according to the anatomical location of the hematoma.

METHODS

1. Patient Selection

From January 2003 to February 2016, the medical records of all consecutive patients who were hospitalized for SISBH at 2 tertiary referral hospitals in Korea (Seoul National University Hospital and Seoul National University Bundang Hospital) were retrospectively reviewed. All patients in whom intramural small intestinal hematoma was detected on the CT scan of the abdomen and pelvis were included in this study. Intramural small bowel hematoma was characterized as circumferential bowel wall thickening, luminal narrowing, and intestinal tract obstruction on the CT scan [6]. Any additional modality for small bowel evaluation including CT enterography, magnetic resonance enterography, capsule endoscopy and enteroscopy was not performed in the study population. Among these patients, those with a history of trauma or iatrogenic interventions including intraabdominal surgery or non-surgical procedures within 4 weeks from the presentation of the intramural hematoma were excluded. This study was approved by the Institutional Review Board Committee at the participating medical centers (SNUH IRB No. 1606-079-771; SNUBH IRB No. B-1608-359-401). The informed consent has been omitted. Because this study was a retrospective review of the patient’s medical records, there was no additional risk to the patient.

2. Study Protocol

Data such as age, sex, body weight, and medical history including diabetes mellitus, hypertension, cardiac arrhythmia, congestive heart failure, coronary heart disease, pulmonary thromboembolism, deep vein thrombosis, peripheral arterial disease, history of heart valve replacement, history of cerebrovascular accidents, and malignancy were collected. The Charlson comorbidity index was calculated to evaluate the severity of comorbidities in the study population. With each elevated level of the Charlson comorbidity index, there are stepwise increases in the cumulative mortality attributable to comorbid diseases [35]. The use of probable offending drugs including anticoagulants (warfarin, heparin, and novel oral anticoagulants such as dabigatran, rivaroxaban, and apixaban) and antiplatelets (aspirin, clopidogrel, ticlopidine, ticagrelor, and cilostazol) were reviewed. The GI symptoms associated with the presentation of SISBH and initial laboratory findings including white blood cell (WBC) count, hemoglobin level, platelet count, PT, aPTT, serum BUN, creatinine, albumin, and high-sensitivity CRP (hs-CRP) at the time of presentation were also collected. The primary outcome was the requirement for surgery. The secondary outcomes were lengths of fasting and hospital stay, and mortality rate. Oral feeding or enteral nutrition was considered according to the physician’s discretion in patients who were willing to try enteral nutrition and who had no obstructive GI symptoms including nausea, vomiting, and abdominal distension.

3. Statistical Analysis

Baseline characteristics and clinical outcomes according to the location of the hematoma in the small intestine were compared. Continuous variables were compared among the groups using one-way ANOVA with Bonferroni correction. Pearson chi-square test or Fisher exact test was used to calculate the statistical significance of the categorical variables. Continuous variables between prolonged (more than 7 days) and short (7 days or less) hospital stays were also compared using Student t-test. Variables considered predictive factors for prolonged hospital stay were assessed using univariate logistic regression analysis. In addition, variables that were significant in the univariate test were entered into the multivariate logistic regression model to identify independent predictive factors for prolonged hospital stay. P-values less than 0.05 were considered to be statistically significant. All statistical analyses were performed using the SPSS version 21.0 (IBM Corp., Armonk, NY, USA).

RESULTS

1. Baseline Characteristics of the Study Population

From January 2003 to February 2016, a total of 110,698 patients were treated with anticoagulant and/or antiplatelet therapy at the participating medical centers. Among them, a total of 37 consecutive patients with SISBH were enrolled in this study. The annual incidence of SISBH was estimated at 0.003% per year. The study population comprised 19 males (51.4%), and the mean age at presentation with SISBH was 74.1 years (range, 51–89 years). Among these patients, 35 (94.6%) had cardiovascular comorbidities including 22 with hypertension (59.5%), 20 with cardiac arrhythmia (54.1%), 13 with a history of cerebrovascular accidents (35.1%), 10 with congestive heart failure (27.0%), 7 with coronary heart diseases (18.9%), 4 with pulmonary embolism and/or deep vein thrombosis (10.8%), 3 with a history of heart valve replacement (8.1%), and 2 with peripheral arterial diseases (5.4%). Three patients (8.1%) had malignant tumors at the time that SISBH presented, all of whom were being treated with systemic chemotherapy. In total, 29 patients (78.4%) had 2 or more comorbidities, and the mean Charlson comorbidity score was 4.6 points (range, 2–10 points). Warfarin, aspirin, clopidogrel, and LMWH was taken by 30 (81.1%), 5 (13.5%), 1 (2.7%), and 1 (2.7%) patient, respectively. None of the study participants received novel oral anticoagulants. Only 1 patient without any underlying illness, who did not use any anticoagulant or antiplatelet therapies, showed prolongation of PT and aPTT during use of an herbal medication at the time of SISBH presentation. Abdominal pain was the most common complaint at the time of presentation (24 of 37 patients; 64.9%). Nausea and/or vomiting were present in 13 patients (35.1%) and GI bleeding developed in 14 (37.8%). Mean WBC count was 12.9×10³/μL (range, 0.2–31.1×10³/μL), mean hemoglobin level was 11.6 g/dL (range, 4.3–18.3 g/dL), and mean platelet count was 235×10³/μL (range, 19–458×10³/μL). Mean PT was 9.9 INR (range, 0.9–18.2 INR) and mean aPTT was 103 seconds (range, 22.7–180 seconds) (Table 1).

2. Clinical Characteristics of Patients with Spontaneous Intramural Hematoma According to Anatomical Location

Duodenal intramural hematoma was detected in 4 patients (10.8%), jejunal intramural hematoma in 16 (43.2%), and ileal intramural hematoma in 17 (45.9%). Cardiac arrhythmia occurred significantly more frequently in patients with jejunal intramural hematoma (81.3%) than in those with ileal (35.3%) and duodenal intramural (25.0%) hematomas (P =0.012). All 3 patients who were treated with systemic chemotherapy for malignancy had duodenal involvement. The Charlson comorbidity index in patients with duodenal intramural hematoma (6.8±2.5) was significantly higher than in patients with ileal intramural hematoma (3.9±1.9) (P =0.025). Patients who used warfarin had a predominance of jejunoileal involvement, although the difference among the locations of SISBH was not statistically significant. Compared to jejunal and ileal involvement, duodenal intramural hematoma was significantly associated with low levels of WBC, hemoglobin, and platelets in the blood (Table 1).

The clinical characteristics and treatment outcomes of the 4 patients with SISBH with duodenal involvement are shown in Supplementary Table 1. Among them, only 1 patient (25.0%; No. 4) had duodenal intramural hematoma related to coagulopathy, with a prolongation of PT and aPTT because of warfarin use. The 3 remaining patients with malignancy (No. 1-3) had duodenal intramural hematoma that developed in relation to thrombocytopenia within the normal range of PT and aPTT. Cytarabine and idarubicin had been administrated for the treatment of acute myeloid leukemia in 2 patients (patients No. 1 and 2) before presenting with a duodenal intramural hematoma. Patient No. 1 presented with sudden onset abdominal pain on the ninth day of the induction chemotherapy. At presentation, the patient’s platelet count was 66×10³/μL, and the low platelet count persisted for about 4 weeks thereafter. Patient No. 2 presented with vomiting and hematemesis on the 62nd day of the induction chemotherapy. This patient’s initial platelet count was 28×10³/μL. On the 5th day after admission, he was discharged without any remaining clinical signs or symptoms. Neither patient used any anticoagulant or antiplatelet therapies. Patient No. 3 had pancreatic cancer, which had been treated with gemcitabine and cisplatin, and had been on maintenance LMWH for 8 months to treat pulmonary thromboembolism. He visited the emergency department for vomiting with melena the 34th day after his last administration of chemotherapeutic agents. His initial platelet count was 19×10³/μL. His symptoms subsided after discontinuing LMWH and correction of severe thrombocytopenia.

3. Primary and Secondary Clinical Outcomes

All patients were treated successfully with conservative therapy including fasting, blood component transfusion, and/or vitamin K injections. None of the patients underwent surgical therapy for SISBH-related complications. Overt GI bleeding was detected in 14 (37.8%) patients with SISBH. Among them, GI bleeding in all patients improved spontaneously by conservative therapy, except 1 patient who underwent angiographic embolization for ileal angiodysplasias although there was no evidence of active bleeding at the time of angiography. Multi-segmental hematoma in proximal to mid-jejunum was detected only in 1 patient (2.7%) with SISBH, an 80-year-old woman who had been taking warfarin for a cerebral infarction and cardiovascular disease. She complained of abdominal pain and nausea, and the initial laboratory findings showed prolonged PT (9.99 INR). She also improved without any complication by conservative therapy including fasting, parenteral nutrition, a transfusion of fresh frozen plasma and a vitamin K injection within 7 days of hospitalization. Moreover, there was no disease-related mortality in the study population. The mean length of fasting and the hospital stay were 3.38 days (range, 0–22 days) and 9.35 days (range, 1–70 days), respectively. Fourteen patients (37.8%) were hospitalized for more than 7 days (Table 2).

Among the 30 patients who were treated with warfarin, 26 (86.7%) continued warfarin after clinical improvement of the SISBH. Warfarin was switched to dual antiplatelet therapy with aspirin and clopidogrel in 2 patients, and to a novel oral anticoagulant (rivaroxaban and dabigatran) in 2 other patients. During the mean follow-up duration of 49.9 months (range, 5–153 months), recurrent SISBH developed in only 1 patient (2.7%) who was on warfarin therapy for a prosthetic heart valve 12 years after the presentation of the first SISBH.

4. Predictive Factors for a Longer Length of Hospital Stay

Prolonged hospital stay of more than 7 days was significantly associated with female gender (P =0.045), lower body weight (P =0.011), a history of cerebrovascular accidents (P =0.039), lower WBC counts (P =0.017), lower hemoglobin level (P =0.016), and lower albumin level (P =0.013), respectively (Supplementary Table 2). The multivariate analysis revealed that body weight less than 60 kg (OR, 12.213; 95% CI, 1.755–84.998; P =0.011) and a history of cerebrovascular accident (OR, 6.667; 95% CI, 1.121–39.650; P =0.037) were independent predictors for prolonged hospital stay (Table 3).

DISCUSSION

In this retrospective cohort study of 37 patients from 2 tertiary referral hospitals over 13 years, the clinical features and prognosis of SISBH were evaluated. To the best of our knowledge, this is the largest study done to determine the clinical characteristics of SISBH, especially according to the anatomical location of the hematoma.

A literature review of the MEDLINE database identified 40 published articles within the previous 30 years, with a total of 103 cases with SISBH that were analyzed [6-34,36-46]. The mean age of patients with SISBH was 62.2 years. Abdominal pain (72.8%) was the most frequent symptom at presentation in patients with SISBH, which is consistent with our results. Medication use (78.6%), including anticoagulant and antiplatelet therapy, was the most common cause of SISBH followed by hemophilia (4.9%), pancreatic diseases (3.9%), liver failure (1.9%), leukemia (1.0%), idiopathic thrombocytopenic purpura (1.0%), von Willebrand disease (1.0%), lupus (1.0%), and Glanzmann’s thrombasthenia (1.0%). Among the medications inducing SISBH, warfarin (73.8%) was the agent most frequently associated with the presentation of SISBH. In this study population, warfarin also contributed to the presentation of SISBH in 30 patients (81.1%). Moreover, more than 90% of patients with SISBH had cardiovascular comorbidities, of which hypertension and cardiac arrhythmia were the most common. These findings are consistent with a causal association between anticoagulant and antiplatelet therapy and SISBH, and suggest that cardiovascular diseases, not hemophilias, are the most critical comorbidities in patients with SISBH. This is because most studies included in the literature review were case reports or case series, which are descriptions of rare and unpredictable observations in clinical practice.

In the literature review, jejunal, ileal, and duodenal intramural hematoma was confirmed in 39 (37.9%), 25 (24.3%), and 18 (17.5%) patients, respectively. Three cases (2.9%) with SISBH involved diffuse segments of the small intestine and the involved segments of SISBH in the remaining 18 cases were unspecified. The predominance of jejunoileal involvement in SISBH was consistent with the results in our study. The reason why the duodenum is rarely involved in SISBH remains unclear. Because the duodenum is the shortest part of the small intestine, and is fixed and compressed by surrounding extraluminal organs, a duodenal intramural hematoma may be more easily compressed by the tissues and absorbed compared to those in the jejunum or ileum.

In this study, 2 patients with acute myeloid leukemia and thrombocytopenia experienced duodenal intramural hematomas. The other patient was diagnosed with duodenal intramural hematoma associated with newly detected thrombocytopenia while being treated with systemic chemotherapy for pancreatic cancer. The platelet counts in patients with duodenal intramural hematoma were significantly lower than those who had jejunoileal involvement. In addition, patients with SISBH with duodenal involvement had significantly more severe comorbidities as estimated by the Charlson comorbidity index compared to jejunoileal involvement. In the literature review, the proportion of cases where warfarin contributed to duodenal intramural hematoma was relatively small compared to the proportion with jejunoileal involvement. Also, case reports described that pancreatic diseases, including acute pancreatitis or pancreatic cancer, were related to duodenal intramural hematoma (Table 4) [34,42-44]. Taken together, the development of spontaneous duodenal intramural hematoma appears to be associated with thrombocytopenia in patients with severe comorbidities, such as malignancy or pancreatic diseases, rather than warfarin use. Duodenal involvement in SISBH is a rare event and its pathogenesis is difficult to clarify, but it seems to be caused by a different mechanism than jejunoileal intramural hematoma.

In the 103 patients with SISBH identified in the literature review, 18 (17.5%) required surgical treatment for peritonitis, intestinal obstruction, or necrotizing pancreatitis. There were 6 deaths (5.8%) and the causes of death were sepsis or multi-organ failure. In this study, however, all patients who presented with SISBH recovered after conservative management, without surgery. Recently, some reports showed that GI obstructive symptoms of SISBH could be treated conservatively without any sequelae, even in cases of extensively long segmental involvement of the hematoma [13,15,27,45,46]. Moreover, early detection of intramural hematoma is crucial because most patients with SISBH can be treated successfully without surgery [47]. Because the SISBH was detected and treated within 14 days (median, 2.5 days), the clinical prognosis of SISBH was favorable in our study.

In our study population, a prolonged hospital length of stay more than 7 days was significantly associated with low body weight of less than 60 kg and a history of cerebrovascular accident, respectively. Underweight is considered a risk for malnutrition [48], and was associated with a prolonged hospital stay in various populations such as patients undergoing pelvic exenteration or cardiac surgery [49,50]. Physical disabilities complicated by stroke were closely linked to a prolonged hospital length of stay, and poor participation in physical therapy of inpatients with functional impairments extended the hospital length of stay [51]. The acute symptoms caused by SISBH might delay the recovery of patients with functional impairment due to stroke.

In conclusion, compared to jejunal and ileal involvement, thrombocytopenia may result in spontaneous duodenal intramural hematoma among patients who are treated with systemic chemotherapy for malignancies. Patients with SISBH have excellent clinical outcomes with conservative therapy regardless of the anatomical location of the hematoma.

NOTES

FINANCIAL SUPPORT

The authors received no financial support for the research, authorship, and/or publication of this article.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTION

Conceptualization: Kang EA and Han SJ. Methodology: Han SJ and Chun J. Data collecting and Formal analysis: Chun J, Lee HJ, Chung HS, and Yoon H. Project administration: Im JP, Kim SG, Kim N, and Lee DH. Visualization: Shin CM and Park YS. Writing-original draft: Han SJ and Chun J. Writingreview and editing: Kang EA, Chun J, Kim JS, and Jung HC. Approval of final manuscript: all authors.

Supplementary Materials

Supplementary Table 1.

Clinical Characteristics and Outcomes of 4 Patients with Duodenal Involvement

ir-2018-00085-suppl.pdf

Supplementary Table 2.

Comparison of Characteristics and Outcomes Regarding Duration of Hospital Stay

ir-2018-00085-suppl.pdf

Table 1.

Baseline Characteristics of Study Population According to Location of Hematoma

Variable	Duodenum	Jejunum	Ileum	P-value
No. of patient	4 (10.8)	16 (43.2)	17 (45.9)	-
Age (yr)	73.8±4.3	76.3±6.8	72.1±9.2	0.331
Male sex	3 (75.0)	9 (56.3)	7 (41.2)	0.416
Body weight (kg)	64.8±5.7	60.6±13.9	55.1±10.1	0.220
BMI (kg/m²)	25.0±2.8	23.8±4.0	22.3±3.0	0.288
Underlying illness
Hypertension	2 (50.0)	12 (75.0)	8 (47.1)	0.242
Arrhythmia	1 (25.0)	13 (81.3)	6 (35.3)	0.012
Cerebrovascular accident	2 (50.0)	6 (37.5)	5 (29.4)	0.715
Congestive heart failure	0	5 (31.3)	5 (29.4)	0.258
Coronary heart disease	0	5 (31.3)	2 (11.8)	0.214
Diabetes mellitus	1 (25.0)	5 (31.3)	2 (11.8)	0.391
Pulmonary or deep vein thromboembolism	1 (25.0)	0	3 (17.6)	0.189
Heart valve replacement	0	0	3 (17.6)	0.147
Peripheral arterial disease	0	1 (6.3)	1 (5.9)	0.879
Malignancy	3 (75.0)	0	0	0.001
Charlson comorbidity index	6.8±2.5	4.7±1.5	3.9±1.9	0.147^a, 0.025^b
Medications				0.057
Warfarin	1 (25.0)	13 (81.3)	12 (70.6)
Warfarin and aspirin	0	1 (6.3)	2 (11.8)
Aspirin	0	0	2 (11.8)
Warfarin and clopidogrel	0	1 (6.3)	0
Low molecular weight heparin	1 (25.0)	0	0
Complaint at the time of presentation
Nausea and/or vomiting	0	7 (43.8)	6 (35.3)	0.261
GI bleeding	3 (75.0)	4 (25.0)	7 (41.2)	0.169
Abdominal pain	1 (25.0)	11 (68.8)	12 (70.6)	0.208
Initial laboratory findings
White blood cell count (×10³/μL)	4.9±7.5	14.2±4.6	13.6±6.0	0.016^a, 0.026^b
Hemoglobin level (g/dL)	7.9±1.2	12.3±2.8	11.8±3.2	0.032^a, 0.070^b
Platelet count (×10³/μL)	83.5±93.9	234.6±64.8	271.5±89.3	0.005^a, <0.001^b
BUN level (mg/dL)	48.5±14.3	28.4±14.5	30.1±14.4	0.052
Creatinine level (mg/dL)	1.5±0.6	1.3±0.8	1.2±0.5	0.746
Albumin level (g/dL)	3.3±0.3	3.7±0.4	3.7±0.5	0.196
hs-CRP level (mg/dL)	6.9±5.0	5.2±3.9	5.9±6.7	0.853
PT, INR	5.3±8.3	10.3±4.9	10.6±5.5	0.227
aPTT (sec)	58.0±42.6	100.1±49.2	116.5±46.7	0.096

Values are presented as number (%) or mean±SD.

^a P-value between duodenum and jejunum group.

^b P-value between duodenum and ileum group.

hs-CRP, high-sensitivity CRP.

Table 2.

Clinical Outcomes in Study Population According to Location of Hematoma

Variable	Duodenum	Jejunum	Ileum	P-value
Requirement for surgery	0	0	0	-
Disease-related mortality	0	0	0	-
Length of fasting (day)	4.50 (3–7)	3.44 (0–22)	3.06 (0–11)	0.807
Length of hospital stay (day)	15.00 (5–27)	10.13 (1–70)	7.29 (1–19)	0.501
Stay in hospital for >7 day	3 (75.0)	5 (31.3)	6 (35.3)	0.353

Values are presented as number (%) or mean (range).

Table 3.

Predictive Factors of Hospital Stay for More Than 7 days

Variable	Length of hospital stay		Univariate analysis		Multivariate analysis
Variable	≤7 day	>7 day	OR (95% CI)	P-value	OR (95% CI)	P-value
Female sex	8 (34.8)	10 (71.4)	4.687 (1.108–19.834)	0.036	-	-
Body weight <60 kg	9 (39.1)	12 (85.7)	9.333 (1.679–51.875)	0.011	12.213 (1.755–84.998)	0.011
History of cerebrovascular accidents	5 (21.7)	8 (57.1)	4.800 (1.126–20.460)	0.034	6.667 (1.121–39.650)	0.037
White blood cell count <10⁴/μL	4 (17.4)	7 (50.0)	4.750 (1.056–21.360)	0.042	-	-
Hemoglobin level <10 g/dL	4 (17.4)	7 (50.0)	4.750 (1.056–21.360)	0.042	-	-
Albumin level ≤3.5 g/dL	4 (17.4)	7 (50.0)	8.550 (1.841–39.702)	0.006	-	-
Length of fasting >3 day	4 (17.4)	7 (50.0)	4.750 (1.056-21.360)	0.042	-	-

Table 4.

Etiology of the Location Specified 82 Cases from the Literature Review

Variable	Duodenum	Jejunum	Ileum	P-value
Warfarin	6 (33.3)	27 (69.2)	17 (68.0)	0.028
Low molecular weight heparin	0	1 (2.6)	2 (8.0)
Aspirin	1 (5.6)	0	0
Hemophilia	1 (5.6)	2 (5.1)	1 (4.0)
Pancreatic disease	4 (22.2)	0	0	0.002
Von Willebrand disease	1 (5.6)	0	0
Glanzmann’s thrombasthenia	1 (5.6)	0	0
Total^a	18	39	25

Values are presented as number (%).

^a Total number including cases with unspecified etiology.

REFERENCES

1. Mc Lauchlan. Fatal false aneurysmal tumour occupying nearly the whole of the duodenum. Lancet 1838;30:203–205.Article
2. Wiot JF, Weinstein AS, Felson B. Duodenal hematoma induced by coumarin. Am J Roentgenol Radium Ther Nucl Med 1961;86:70–75.PubMed
3. Segaul AI, Mills M, Wertheimer HM. Intramural hematoma of the small intestine as a complication of anticoagulant therapy. Am J Surg 1964;107:891–894.Article PubMed
4. Kramer RA, Hill RL. Intramural small bowel bleeding during anticoagulant therapy. Arch Intern Med 1964;113:213–217.Article PubMed
5. Bettler S, Montani S, Bachmann F. Incidence of intramural digestive system hematoma in anticoagulation: epidemiologic study and clinical aspects of 59 cases observed in Switzerland (1970-1975). Schweiz Med Wochenschr 1983;113:630–636.PubMed
6. Altintoprak F, Dıkıcıer E, Akyüz M, et al. A retrospective review of patients with non-traumatic spontaneous intramural hematoma. Turk J Gastroenterol 2013;24:392–399.Article PubMed
7. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel hematoma: imaging findings and outcome. AJR Am J Roentgenol 2002;179:1389–1394.Article PubMed
8. Yoldaş T, Erol V, Çalışkan C, Akgün E, Korkut M. Spontaneous intestinal intramural hematoma: what to do and not to do. Ulus Cerrahi Derg 2013;29:72–75.Article PubMed PMC
9. Kones O, Dural AC, Gonenc M, et al. Intramural hematomas of the gastrointestinal system: a 5-year single center experience. J Korean Surg Soc 2013;85:58–62.Article PubMed PMC
10. Carkman S, Ozben V, Saribeyoğlu K, et al. Spontaneous intramural hematoma of the small intestine. Ulus Travma Acil Cerrahi Derg 2010;16:165–169.PubMed
11. Chaiteerakij R, Treeprasertsuk S, Mahachai V, Kullavanijaya P. Anticoagulant-induced intramural intestinal hematoma: report of three cases and literature review. J Med Assoc Thai 2008;91:1285–1290.PubMed
12. Erkan G, Çalişkan A, Kaan Ataç G, Akpinar EE, Çoban M, Değertekın B. Spontaneous intramural jejunal hematoma: two cases. Turk J Gastroenterol 2012;23:615–616.Article PubMed
13. Altikaya N, Parlakgümüş A, Demır Ş, Alkan Ö, Yildirim T. Small bowel obstruction caused by intramural hematoma secondary to warfarin therapy: a report of two cases. Turk J Gastroenterol 2011;22:199–202.Article PubMed
14. Uzun MA, Koksal N, Gunerhan Y, Sahin UY, Onur E, Ozkan OF. Intestinal obstruction due to spontaneous intramural hematoma of the small intestine during warfarin use: a report of two cases. Eur J Emerg Med 2007;14:272–273.Article PubMed
15. Limmer AM, Clement Z. Extensive small bowel intramural haematoma secondary to warfarin. J Surg Case Rep 2017;2017:rjx044.Article PubMed PMC PDF
16. Pimenta JM, Saramet R, Pimenta de Castro J, Pereira LG. Overlooked complication of anticoagulant therapy. The intramural small bowel hematoma: a case report. Int J Surg Case Rep 2017;39:305–308.Article PubMed PMC
17. Pamukçu Günaydın G, Çiftçi Sivri HD, Sivri S, Otal Y, Özhasenekler A, Kurtoğlu Çelik G. Concurrent spontaneous sublingual and intramural small bowel hematoma due to warfarin use. Case Rep Emerg Med 2015;2015:583869.Article PubMed PMC PDF
18. Abdel Samie A, Sun R, Huber A, Höpfner W, Theilmann L. Spontaneous intramural small-bowel hematoma secondary to anticoagulant therapy: a case series. Med Klin Intensivmed Notfmed 2013;108:144–148.Article PubMed
19. Zammit A, Marguerat DG, Caruana C. Anticoagulation-induced spontaneous intramural small bowel haematomas. BMJ Case Rep 2013;2013:bcr2013008831.Article PubMed PMC
20. Brar P, Singh I, Kaur S, et al. Anticoagulant-induced intramural hematoma of the jejunum. Clin J Gastroenterol 2011;4:387–390.Article PubMed
21. Ho MP, Tsai KC, Cheung WK, Wang KL. Spontaneous intramural small bowel hematoma associated with warfarin nonadherence in an elderly patient. J Am Geriatr Soc 2010;58:608–609.Article PubMed
22. Seo JY, Jeon TJ, Oh TH. Nontraumatic spontaneous intramural small-bowel hematoma caused by warfarin-induced overanticoagulation. Clin Gastroenterol Hepatol 2009;7:A36.Article PubMed
23. Alberto SF, Sánchez P, Felix J, Deus JR. Non-traumatic spontaneous intramural hematoma of the small bowel: an infrequent complication of anticoagulation therapy. Gastroenterol Hepatol 2009;32:346–348.Article PubMed
24. Hou SW, Chen CC, Chen KC, Ko SY, Wong CS, Chong CF. Sonographic diagnosis of spontaneous intramural small bowel hematoma in a case of warfarin overdose. J Clin Ultrasound 2008;36:374–376.Article PubMed
25. Cheng J, Vemula N, Gendler S. Small bowel obstruction caused by intramural hemorrhage secondary to anticoagulant therapy. Acta Gastroenterol Belg 2008;71:342–344.PubMed
26. Sorbello MP, Utiyama EM, Parreira JG, Birolini D, Rasslan S. Spontaneous intramural small bowel hematoma induced by anticoagulant therapy: review and case report. Clinics (Sao Paulo) 2007;62:785–790.Article PubMed PDF
27. Arain J, Al-Dabbagh A. Gastric outlet obstruction secondary to spontaneous intramural haematoma as a complication of warfarin treatment. J Surg Case Rep 2012;2012:13.Article PDF
28. Chen YW, Chen MH, Wang LM, Chen YC. Spontaneous intramural intestinal haematoma. Intern Med J 2007;37:661–662.Article PubMed
29. Farhoud S, Stephani SM, Bromberg SH. Acute pancreatitis due to intramural hematoma of the duodenum by the use of anticoagulants. Arq Gastroenterol 2001;38:53–56.Article PubMed PDF
30. Spinelli G, Damiano G, Palumbo VD, et al. Ileus following spontaneous jejunum intramural hematoma: case report and review of the literature. Acta Clin Croat 2012;51:435–439.PubMed
31. McClain LE, Pullatt RC. Spontaneous intramural hematoma of the ileum associated with obstruction during low-molecular-weight heparin use. Am Surg 2013;79:E3–E5.Article PubMed
32. Shaw PH, Ranganathan S, Gaines B. A spontaneous intramural hematoma of the bowel presenting as obstruction in a child receiving low-molecular-weight heparin. J Pediatr Hematol Oncol 2005;27:558–560.Article PubMed
33. Basir N, Chong VH. Spontaneous intramural duodenal haematoma with transient biliary obstruction and acute cholecystitis. Singapore Med J 2010;51:e198–e200.PubMed
34. Dugernier TL, Breuskin FM. Duodenal air dissection secondary to intramural hematoma in necrotizing pancreatitis. Endoscopy 2002;34:1024.Article PubMed PDF
35. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383.Article PubMed
36. Katsumi A, Matsushita T, Hirashima K, et al. Recurrent intramural hematoma of the small intestine in a severe hemophilia A patient with a high titer of factor VIII inhibitor: a case report and review of the literature. Int J Hematol 2006;84:166–169.Article PubMed
37. Santoro R, Iannaccaro P. Spontaneous intramural intestinal haemorrhage in a haemophiliac patient. Br J Haematol 2004;125:419.Article PubMed
38. Gamba G, Maffé GC, Mosconi E, Tibaldi A, Di Domenico G, Frego R. Ultrasonographic images of spontaneous intramural hematomas of the intestinal wall in two patients with congenital bleeding tendency. Haematologica 1995;80:388–389.PubMed
39. Nogués A, Eizaguirre I, Suñol M, Tovar JA. Giant spontaneous duodenal hematoma in hemophilia A. J Pediatr Surg 1989;24:406–408.Article PubMed
40. Eichele DD, Ross M, Tang P, Hutchins GF, Mailliard M. Spontaneous intramural duodenal hematoma in type 2B von Willebrand disease. World J Gastroenterol 2013;19:7205–7208.Article PubMed PMC
41. DeRose JJ Jr, Diamond S, Bergman K. Spontaneous duodenal hematoma in a patient with Glanzmann’s thrombasthenia. J Pediatr Surg 1997;32:1341–1343.Article PubMed
42. Eurboonyanun C, Somsap K, Ruangwannasak S, Sripanaskul A. Spontaneous intramural duodenal hematoma: pancreatitis, obstructive jaundice, and upper intestinal obstruction. Case Rep Surg 2016;2016:5321081.Article PubMed PMC PDF
43. Khurana T, Shah A, Ali I, Islam R, Siddiqui AA. Intramural duodenal hematoma with acute pancreatitis in a patient with an overt pancreatic malignancy. ACG Case Rep J 2014;1:209–211.Article PubMed PMC
44. Dubois J, Guy F, Porcheron J. A pancreatic-induced intramural duodenal hematoma: a case report and literature review. Hepatogastroenterology 2003;50:1689–1692.PubMed
45. Weil BR, Howard TJ, Zyromski NJ. Spontaneous duodenal hematoma: a rare cause of upper gastrointestinal tract obstruction. Arch Surg 2008;143:794–796.Article PubMed
46. Delgado Ramos GM, Piovezani Ramos G, Cotter TG. Spontaneous intramural small bowel hematoma in a patient with acute myeloid leukaemia receiving chemotherapy and nilotinib. BMJ Case Rep 2017;2017:bcr-2017-220439.Article PubMed
47. Abdel Samie A, Theilmann L. Detection and management of spontaneous intramural small bowel hematoma secondary to anticoagulant therapy. Expert Rev Gastroenterol Hepatol 2012;6:553–558.Article PubMed
48. Task Force of A.S.P.E.N; American Dietetic Association Dietitians in Nutrition Support Dietetic Practice Group; Russell M, et al. American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and American Dietetic Association (ADA): standards of practice and standards of professional performance for registered dietitians (generalist, specialty, and advanced) in nutrition support. Nutr Clin Pract 2007;22:558–586.Article PubMed
49. Guo Y, Chang E, Bozkurt M, Park M, Liu D, Fu JB. Factors affecting hospital length of stay following pelvic exenteration surgery. J Surg Oncol 2018;117:529–534.Article PubMed
50. Ranucci M, Ballotta A, La Rovere MT, Castelvecchio S, Surgical and Clinical Outcome Research (SCORE) Group. Postoperative hypoxia and length of intensive care unit stay after cardiac surgery: the underweight paradox? PLoS One 2014;9:e93992.Article PubMed PMC
51. Lenze EJ, Munin MC, Quear T, et al. Significance of poor patient participation in physical and occupational therapy for functional outcome and length of stay. Arch Phys Med Rehabil 2004;85:1599–1601.Article PubMed

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Clinical features and outcomes in spontaneous intramural small bowel hematoma: cohort study and literature review

Intest Res. 2019;17(1):135-143. Published online October 10, 2018

DOI: https://doi.org/10.5217/ir.2018.00085

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Clinical features and outcomes in spontaneous intramural small bowel hematoma: cohort study and literature review

Variable	Duodenum	Jejunum	Ileum	P-value
No. of patient	4 (10.8)	16 (43.2)	17 (45.9)	-
Age (yr)	73.8±4.3	76.3±6.8	72.1±9.2	0.331
Male sex	3 (75.0)	9 (56.3)	7 (41.2)	0.416
Body weight (kg)	64.8±5.7	60.6±13.9	55.1±10.1	0.220
BMI (kg/m²)	25.0±2.8	23.8±4.0	22.3±3.0	0.288
Underlying illness
Hypertension	2 (50.0)	12 (75.0)	8 (47.1)	0.242
Arrhythmia	1 (25.0)	13 (81.3)	6 (35.3)	0.012
Cerebrovascular accident	2 (50.0)	6 (37.5)	5 (29.4)	0.715
Congestive heart failure	0	5 (31.3)	5 (29.4)	0.258
Coronary heart disease	0	5 (31.3)	2 (11.8)	0.214
Diabetes mellitus	1 (25.0)	5 (31.3)	2 (11.8)	0.391
Pulmonary or deep vein thromboembolism	1 (25.0)	0	3 (17.6)	0.189
Heart valve replacement	0	0	3 (17.6)	0.147
Peripheral arterial disease	0	1 (6.3)	1 (5.9)	0.879
Malignancy	3 (75.0)	0	0	0.001
Charlson comorbidity index	6.8±2.5	4.7±1.5	3.9±1.9	0.147^a, 0.025^b
Medications				0.057
Warfarin	1 (25.0)	13 (81.3)	12 (70.6)
Warfarin and aspirin	0	1 (6.3)	2 (11.8)
Aspirin	0	0	2 (11.8)
Warfarin and clopidogrel	0	1 (6.3)	0
Low molecular weight heparin	1 (25.0)	0	0
Complaint at the time of presentation
Nausea and/or vomiting	0	7 (43.8)	6 (35.3)	0.261
GI bleeding	3 (75.0)	4 (25.0)	7 (41.2)	0.169
Abdominal pain	1 (25.0)	11 (68.8)	12 (70.6)	0.208
Initial laboratory findings
White blood cell count (×10³/μL)	4.9±7.5	14.2±4.6	13.6±6.0	0.016^a, 0.026^b
Hemoglobin level (g/dL)	7.9±1.2	12.3±2.8	11.8±3.2	0.032^a, 0.070^b
Platelet count (×10³/μL)	83.5±93.9	234.6±64.8	271.5±89.3	0.005^a, <0.001^b
BUN level (mg/dL)	48.5±14.3	28.4±14.5	30.1±14.4	0.052
Creatinine level (mg/dL)	1.5±0.6	1.3±0.8	1.2±0.5	0.746
Albumin level (g/dL)	3.3±0.3	3.7±0.4	3.7±0.5	0.196
hs-CRP level (mg/dL)	6.9±5.0	5.2±3.9	5.9±6.7	0.853
PT, INR	5.3±8.3	10.3±4.9	10.6±5.5	0.227
aPTT (sec)	58.0±42.6	100.1±49.2	116.5±46.7	0.096

Variable	Duodenum	Jejunum	Ileum	P-value
Requirement for surgery	0	0	0	-
Disease-related mortality	0	0	0	-
Length of fasting (day)	4.50 (3–7)	3.44 (0–22)	3.06 (0–11)	0.807
Length of hospital stay (day)	15.00 (5–27)	10.13 (1–70)	7.29 (1–19)	0.501
Stay in hospital for >7 day	3 (75.0)	5 (31.3)	6 (35.3)	0.353

Variable	Length of hospital stay		Univariate analysis		Multivariate analysis
Variable	≤7 day	>7 day	OR (95% CI)	P-value	OR (95% CI)	P-value
Female sex	8 (34.8)	10 (71.4)	4.687 (1.108–19.834)	0.036	-	-
Body weight <60 kg	9 (39.1)	12 (85.7)	9.333 (1.679–51.875)	0.011	12.213 (1.755–84.998)	0.011
History of cerebrovascular accidents	5 (21.7)	8 (57.1)	4.800 (1.126–20.460)	0.034	6.667 (1.121–39.650)	0.037
White blood cell count <10⁴/μL	4 (17.4)	7 (50.0)	4.750 (1.056–21.360)	0.042	-	-
Hemoglobin level <10 g/dL	4 (17.4)	7 (50.0)	4.750 (1.056–21.360)	0.042	-	-
Albumin level ≤3.5 g/dL	4 (17.4)	7 (50.0)	8.550 (1.841–39.702)	0.006	-	-
Length of fasting >3 day	4 (17.4)	7 (50.0)	4.750 (1.056-21.360)	0.042	-	-

Variable	Duodenum	Jejunum	Ileum	P-value
Warfarin	6 (33.3)	27 (69.2)	17 (68.0)	0.028
Low molecular weight heparin	0	1 (2.6)	2 (8.0)
Aspirin	1 (5.6)	0	0
Hemophilia	1 (5.6)	2 (5.1)	1 (4.0)
Pancreatic disease	4 (22.2)	0	0	0.002
Von Willebrand disease	1 (5.6)	0	0
Glanzmann’s thrombasthenia	1 (5.6)	0	0
Total^a	18	39	25

Table 1. Baseline Characteristics of Study Population According to Location of Hematoma

Values are presented as number (%) or mean±SD.

P-value between duodenum and jejunum group.

P-value between duodenum and ileum group.

hs-CRP, high-sensitivity CRP.

Table 2. Clinical Outcomes in Study Population According to Location of Hematoma

Values are presented as number (%) or mean (range).

Table 3. Predictive Factors of Hospital Stay for More Than 7 days

Table 4. Etiology of the Location Specified 82 Cases from the Literature Review