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From the question on page 1073

The patient had jejunal volvulus with intramural haematoma.

The international normalised ratio of prothrombin time on arrival was more than 8. Figures 1 and 2 in the question section show haemorrhagic ascites and nautilus-shaped jejunal volvulus with oedematous and hyperattenuated intestinal walls,which were compatible with intramural haematoma. Warfarin was discontinued upon arrival and intravenous vitamin K, together with fresh frozen plasma was given. At laparotomy a strangulated volvulus was found and treated by a segmental resection of 30 cm of jejunum. Histopathology revealed transmural haemorrhagic necrosis of the thickened jejunal wall (fig 1A,B, below). The patient made a smooth recovery.

Figure 1 Histopathology showed (A) submucosal haemorrhage and (B) fresh haemorrhage involving muscle layers. (Haematoxylin & eosin stain; original magnification, ×40.)

Warfarin is a commonly prescribed anticoagulant. This case demonstrates a rare complication of warfarin overdose leading to intramural haematoma, which may be the cause of jejunal volvulus and the subsequent strangulation. Cases of warfarin-related intramural haematoma have been reported. The clinical presentations vary from mild and vague abdomianl pain to intestinal obstruction and acute abdomen.1 The sites most frequently involved are proximal jejunum and duodenum with a lenght of involvement between 10 and 30 cm.2 3 Abdominal ultrasound and computed tomography (CT) scan are relevant for accurate diagnosis.4 The ultrasonographic feature of acute intramural haematoma in small intestines consists of thickened and echogenic submucosal layers.5 Non-enhanced abdominal CT scan shows homogenous hyperattenuation of symmetrically thickened bowels, indicating intramural haematoma, which will not be enhanced.13 These are helpful in differentiating with other infiltrativ processes involving small bowels such as malignancy, infection or inflammation.3

It is crucial for clinicians to be reminded of this unusual complication of warfarin overdose because prompt diagnosis is the key to reducing morbidity and mortality. In cases without intestinal obstruction or peritonitis, conservative therapy is the treatment of choice.1 For patients complicated by small intestinal volvulus, early surgical intervention is needed to prevent vascular compromise.

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