Spontaneous Intramural Small-Bowel Hematoma

Spontaneous intramural hematoma of the small bowel is most often attributed to over-anticoagulation with warfarin. Other causes include bleeding disorders, malignancy, vasculidities, and trauma. Typically, the duodenum and jejunum are involved. 

The hemorrhage is usually in the submucosal layer of the small bowel. Intraluminal, intramesenteric, and retroperitoneal extension can occur. Hemorrhagic ascites may be present.

The CT appearance depends on the age of the hematoma. Initially, thickened small bowel loops with intramural hyperdensity will be seen. As the clot lyses, the attenuation decreases and the thickened bowel wall appears hypodense.

Treatment consists of normalizing the INR with bowel resection reserved for cases presenting with high grade bowel obstruction. Follow up imaging will demonstrate a resolution of CT findings within a few weeks.

The above clip is from a patient with a history of atrial fibrillation on warfarin who presented with a 5 day history of vague abdominal pain and was found to have a supratherapeutic INR. CECT demonstrated hemorrhagic ascites with thickened, hyperdense loops of jejunum.

REFERENCES

Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel hematoma: imaging findings and outcomes. AJR Am J Roentgenol. 2002 Dec;179(6):1389-94.
Boudiaf M, Soyer P, Terem C, et al. CT evaluation of small bowel obstruction. Radiographics. 2001 May;21:613-24.