Spontaneous intramural jejunal hematoma presenting as small bowel obstruction in a patient with warfarin over-anticoagulation: a case report

Spontaneous intramural small bowel hematoma is a rare complication of anticoagulant therapy that can mimic acute abdomen or mechanical bowel obstruction. This report describes a 66-year-old man with valvular heart disease who was receiving long-term warfarin therapy after surgical aortic valve replacement and presented with diffuse abdominal pain. Computed tomography revealed long-segment bowel wall thickening of the distal jejunum with submucosal edema, findings consistent with an intramural hematoma. During hospitalization, the patient developed a marked hemoglobin decrease, from 13.0 to 6.0 g/dL, along with radiological progression of the hematoma and hemoperitoneum. However, he remained hemodynamically stable and was successfully managed conservatively with bowel rest, intravenous vitamin K, and transfusion of fresh frozen plasma and packed red blood cells. This case suggests that spontaneous intramural small bowel hematoma should be considered in the differential diagnosis of acute abdomen in anticoagulated patients. Even in the presence of severe anemia and hemoperitoneum, conservative management may be safe and effective in hemodynamically stable patients and may help avoid unnecessary surgical intervention.