Old woman with acute abdominal pain



Doctor's Information

Name : Hamidreza
Family : Haghighatkhah
Affiliation :Radiology Department,Shohada Tajrish Hospital,SBMU
Academic Degree : Associate Professor of Radiology
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : Mohammad Ali karimi


Case Section

Abdominal Imaging


Patient's Information

Gender : Female
Age : 67


Clinical Summary

A 67 year old woman with acute abdominal pain who was under anticoagulation with warfarin and her international normalized ratio (INR) at presentation was 8.5.


Imaging Findings

Axial unenhanced abdominopelvic computed tomography images demonstrate heterogeneous circumferential intestinal wall thickening in longitudinal section of duodenal (D3 and D4) and jejunal walls as well as in cross-section of jejunal wall (in the left hemiabdomen) representing intramural hematoma. Proximal duodenum and stomach are dilated due to luminal narrowing and intestinal obstruction caused by intramural hematoma. Abdominopelvic free fluid is seen with some hyperdense areas indicating hemoperitoneum with ongoing bleeding. Dirty mesentery may be due to intramesenteric hemorrhage. Note that the right kidney is not seen (congenital single kidney). No IV contrast material was given because of raised serum creatinine level.


Differential Diagnosis

• Carcinoma
• Lymphoma
• Crohn's disease
• Enteritis (regional)
• Perforated ulcer


Final Diagnosis

Spontaneous doudenojejunal intramural hematoma


Discussion (Related Text)

In contrast to traumatic small bowel hematoma, which mainly affects the duodenum and tends to involve a short intestinal segment, spontaneous small bowel hematoma is more extensive and most commonly involves the jejunum, followed by the ileum and duodenum. The most common cause of this condition is overanticoagulation by warfarin. Other risk factors include hemophilia, idiopathic thrombocytopenic purpura, leukemia, lymphoma, myeloma, chemotherapy, vasculitis, pancreatitis, and pancreatic cancer. Computed tomography (CT) is the key for the diagnosis of this condition. Some authors have suggested that a non-contrast CT scan should be preformed prior to oral and intravenous contrast application, as contrast enhanced scans alone may mask the presence of intramural hemorrhage. Characteristic findings on CT include circumferential wall thickening, intramural hyperdensity, luminal narrowing and intestinal obstruction. The hemorrhage is usually located in the submucosal layer of the bowel and originates from a small vessel that produces slow bleeding. In addition to intramural bleeding, intraluminal, intramesenteric, and retroperitoneal hemorrhage can occur, especially when the duodenum is involved. Hemorrhagic ascites can be present and is related to leakage of blood from an engorged, thickened, and inflamed bowel wall with submucosal bleeding extending into all layers. The sonographic appearance of acute intramural small bowel hematoma consists of a thickened intestinal wall mainly involving the submucosal layer. MRI characteristics of duodenal hematoma include a high signal intensity well-defined concentric ring (ring sign). The unique MRI tissue characteristics (ring with short T1 and long T2 relaxation times) are attributable to the paramagnetic properties of iron species within the hematoma. Isolated duodenal hematoma can be treated conservatively with close clinical monitoring. Nasogastric suction should be initiated due to the edema at the site of injury leading to both mechanical obstruction and decreased peristalsis. Continued obstruction beyond 15 days is an indication for surgical management. Jejunal or duodenal perforation (evidenced by retroperitoneal free fluid or air, extravasation of oral contrast material) is a surgical emergency.



1. Abdel Samie A, Theilmann L. Detection and management of spontaneous intramural small bowel hematoma secondary to anticoagulant therapy. Expert Rev Gastroenterol Hepatol. 2012; 6(5):553-8.
2. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel hematoma: imaging findings and outcome. AJR Am J Roentgenol. 2002; 179(6):1389-94.
3. Chaiteerakij R, Treeprasertsuk S, Mahachai V. Anticoagulant-induced intramural intestinal hematoma: report of three cases and literature review. J Med Assoc Thai. 2008; 91(8):1285-90.


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