Risk factors and management of anticoagulant-induced intramural hematoma of the gastrointestinal tract

Intramural intestinal hematoma is considered a rare complication of overanticoagulation in elderly patients. Nevertheless, this clinical entity is increasingly being reported in the literature, and its incidence is predicted to increase further as a result of the wide use of long-term anticoagulation in an aging population. However, data regarding the risk factors and optimal management of this unusual complication in patients on phenprocoumon/warfarin are scarce.

We retrospectively analyzed the medical reports of patients with intramural gastrointestinal hematoma on anticoagulant therapy who were treated in our unit between January 2008 and July 2011.

Four consecutive patients were identified during the study period. The mean age of the patients was 80 years. All patients were on uninterrupted anticoagulation with phenprocoumon due to chronic atrial fibrillation. Hematoma was localized in the duodenum in one patient, in the jejunum in two patients, and in the rectum in one patient. Hematoma occurred spontaneously in three patients and following a trauma in one patient. Excessive anticoagulation with an INR of >6 was associated with the development of this complication in all spontaneous cases. A combination of computed tomography and sonography established the diagnosis in all four. Conservative therapy proved successful in two patients, and surgery was necessary in two cases.

Intramural hematoma of the gastrointestinal tract should be suspected in any patient with abdominal pain or intestinal obstruction under anticoagulant therapy. Emergency physicians and surgeons should be aware of this rare complication, as most such cases will resolve spontaneously under conservative measures without the need for surgery.