Spontaneous intramural hematoma of the duodenum secondary to anticoagulant drug intoxication

Abstract

Introduction. Duodenal hematomas are commonly traumatic, caused by blunt abdominal trauma. Nontraumatic spontaneous intramural hematomas of the duodenum are rare, and in most cases induced by anticoagulant therapy. The diagnosis is based on clinical and biochemical parameters, endoscopy, and radiological examinations. The objective of this report was to present a clinical and radiological presentation of an intramural duodenal hematoma caused by anticoagulant therapy. Case outline. A 43-year-old female was presented with epigastric pain, nausea, hematemesis, and melena. She had a positive medical history of deep venous thrombosis of the pelvis, which was diagnosed the previous month, for which she received oral anticoagulant therapy (coumarin). Physical examination revealed diffuse abdominal tenderness, while laboratory analyses showed markedly elevated international normalized ratio (INR) of prothrombin time (INR > 7), which indicated the anticoagulant intoxication. Computed tomography (CT) showed luminal narrowing with uniform circumferential wall thickening of the descendent and horizontal part of duodenum, which was hyper dense in the native series and slight and uniform ring-formed enhancement in post-contrast phases, a typical CT presentation of intramural duodenal hematoma. Periduodenal and right sided pararenal hematomas were also visualized. After stopping the anticoagulant therapy and performing conservative treatment (vitamin K) with good therapeutic effect being monitored by physical examination, laboratory analyses and transabdominal ultrasonography, spontaneous resolution of the duodenal hematoma was revealed by follow-up CT examination two weeks after the onset. Conclusion. Ultrasonography and CT are useful diagnostic tools in recognition of the intramural duodenal hematoma and other locations of hemorrhage and in monitoring therapeutic effects.