Spontaneous intramural small bowel hematoma: unusual cause of intestinal subocclusion in an anticoagulated patient—a case report

Background: Spontaneous intramural small bowel hematoma (SISBH) is a rare complication of long-term oral anticoagulation, particularly with vitamin K antagonists (VKAs). SISBH diagnosis is based on oral anticoagulation history associated with acute abdominal symptoms and suggestive radiological findings. Experience with this condition is still limited in the literature. This report highlights the clinical presentation and management of this rare condition, including the first known use of total-body positron emission tomography/computed tomography (PET/CT) scan in the diagnostic workup of SISBH. Case Description: A 53-year-old male on long-term oral anticoagulation with VKA for mechanical mitral valve replacement due to rheumatic heart disease presented to the emergency department for abdominal pain and nausea. Physical examination was remarkable for abdominal distension, increased bowel sounds and rebound tenderness, a presentation compatible with intestinal subocclusion. At admission, the international normalized ratio was 8.3, indicating VKA intoxication. Abdominal CT revealed significant jejunal parietal thickening, suggestive of SISBH. PET/CT findings were also consistent with a possible hematoma, although an inflammatory or neoplastic process could not be excluded. We opted for conservative treatment with temporary warfarin suspension and vitamin K infusion. The patient's intestinal subocclusion gradually improved, and he was discharged after seven days with full recovery. Conclusions: SISBH, although rare, should be considered in the differential diagnosis of acute abdominal symptoms in patients receiving long-term oral anticoagulation, particularly with VKAs. Conservative treatment is the preferred initial option. A high index of suspicion, followed by prompt abdominal CT, is key to early diagnosis. PET/CT provided minimal diagnostic value beyond CT. Conservative management with anticoagulation reversal and supportive care is generally the primary therapeutic strategy adopted in the literature, demonstrating favorable short-term outcomes, as was the case with our patient.