Clinical features of our patients with spontaneous intramural intestinal hematoma and the use of direct oral anticoagulants in the maintenance therapy

Year 2020, Volume: 3 Issue: 3, 201 - 213, 29.12.2020

Cem Karaali , Semra Demirli Atıcı , İsmail Sert , Korhan Tuncer , Mehmet Üstün , Kenan Teker , Mustafa Emiroğlu

Abstract

Aim: Spontaneous intramural intestinal hematoma (SIIH) is a rare complication in patients receiving anticoagulant therapy and usually occurs secondary to warfarin use.
In our study, the clinical characteristics and treatment approaches of SIIH cases will be examined. In addition, our study will share the long-term follow-up’s of SIIH patients who have been shifted to direct oral anticoagulants (DOACs) instead of warfarin as a maintenance treatment for the first time in the literature.
Material and Methods: The data of 21 patients with a diagnosis of SIIH associated with warfarin use between 2015 and 2020 were retrospectively analyzed.
Results: The average age of the patients included in the study was 67.6 ± 12.0 (range: 45-90), 9 of them were female and 12 were male. All of the patients were using warfarin for various diseases. While the most common complaint was abdominal pain, in the physical examination of all patients, abdominal tenderness was detected. In all patients, the INR value was above the therapeutic values ​​at the time of arrival at hospital, and 14 patients had anemia. Abdominal computed tomography (CT) helped diagnose SIIH in all patients. While 18 patients were treated conservatively, 3 patients were operated. One of the operated patients died due to the postoperative pulmonary embolism. While 7 (35%) patients continued with warfarin after discharge, 13 (65%) patients were replaced with DOAC medications. While the mean follow-up period of patients using warfarin is 22.1 ± 18.2 months (range: 8-61), those using DOAC is 26.4 ± 19.3 (range: 6-55) months. During follow-up, no recurrence of SIIH was observed in either group.
Conclusion: In patients using oral anticoagulants, and especially with abdominal pain and elevated INR values, SIIH should be considered among the differential diagnoses. In the treatment of SIIH, firstly, medical treatment options should be tried, but the operation should not be avoided in patients with hemodynamic impairment, acute abdominal findings, or patients who cannot be diagnosed differentially. In addition, DOAC drugs may be considered as an alternative to warfarin in maintenance therapy after SIIH in selected patient groups.

Keywords

Anticoagulant, direct oral anticoagulant drug, small intestine

Supporting Institution

Yok

Project Number

Approval from the institutional research ethics board was obtained (decision number 2020/8-7)

Thanks

We thank all general surgery department staff for their cooperation.

Spontan intramural intestinal hematomlu hastalarımızın klinik özellikleri ve idame tedavisinde direkt oral antikoagulanların kullanımı

Abstract

Amaç: Spontan intramural intestinal hematomlar (SIIH), antikoagulan tedavi alan hastalarda nadir görülen bir komplikasyondur ve genellikle warfarin kullanımına sekonder olarak ortaya çıkar. Çalışmamızda, SIIH olgularının klinik karakteristikleri ve tedavi yaklaşımları incelenecektir. Ayrıca çalışmamız, literatürde ilk kez idame tedavisi olarak warfarin yerine direkt oral antikoagulan(DOAC)’lara çevrilmiş SIIH hastalarının uzun dönem takiplerini de paylaşacaktır.

Yöntem ve Gereçler: 2015-2020 yıllarında warfarin kullanımına bağlı SIIH tanısıyla yatan 21 hastanın verisi retrospektif olarak incelendi.

Bulgular: Çalışmaya alınan hastaların yaş ortalaması 67.6±12.0 (range: 45-90) olup, 9’u kadın 12’si erkek idi. Hastaların tümü çeşitli hastalıklar için warfarin kullanmakta idi. En sık başvuru yakınması karın ağrısı iken, tüm hastaların fizik muayenesinde karında hassasiyet saptandı. Hastaların hepsinde başvuru anında INR değeri terapotik değerlerin üstünde olup, 14 hastada anemi saptanmıştır. Abdomen bilgisayarlı tomografi (BT) hastaların hepsinde SIIH tanısı koymada yardımcı olmuştur. 18 hasta konservatif olarak tedavi edilirken, 3 hastaya operasyon uygulandı. Opere edilen hastalardan birinde postoperatif pulmoner emboli gelişimine bağlı mortalite gelişmiştir. 7 (35%) hastanın taburculuk sonrası tedavisine warfarin ile devam edilmiş iken, 13 (65%) hastanın tedavisi DOAC ilaçlar ile değiştirilmiştir. Warfarin kullanan hastaların takip süresi ortalama 22.1±18.2 ay (range: 8-61) iken, DOAC kullanan hastalarınki 26.4±19.3 (range: 6-55) aydır. Takipte her iki grupta da SIIH nüksü görülmedi.

Tartışma ve Sonuç: Oral antikoagulan kullanan ve özellikle de INR değerleri (seviyeleri) yükselmiş karın ağrılı hastalarda, SIIH ayırıcı tanılar arasında düşünülmelidir. SIIH’lerin tedavisinde öncelikle medikal tedavi seçenekleri denenmeli ancak hemodinamisi bozulan, akut karın bulguları olan ya da ayırıcı tanısı yapılamayan hastalarda ise operasyondan kaçınılmamalıdır. Ayrıca seçilmiş hasta gruplarında SIIH sonrası idame tedavisinde DOAC ilaçlar warfarin’e bir alternatif olarak düşünülebilir.

Keywords

Antikoagulan, direkt oral antikoagulan, ince bağırsak

Project Number

Approval from the institutional research ethics board was obtained (decision number 2020/8-7)

References

• Acar, N., Acar, T., Gungor, F., Kamer, E., Karasu, S., Karaisli, S., Dilek, O. N. (2019). A Rare Complication of Anticoagulant Therapy: Intramural Hematoma of the Small Bowel. Arch Iran Med, 22(11), 653-658.
• Ahn, S. H., Mayo-Smith, W. W., Murphy, B. L., Reinert, S. E., Cronan, J. J. (2002). Acute nontraumatic abdominal pain in adult patients: abdominal radiography compared with CT evaluation. Radiology, 225(1), 159-164.
• Atıcı, S. D., Kuzukıran, D., Çalık, B., Üstün, M., Aydın, C. (2019). Spontaneous Intestinal Intramural Hematoma Due to Warfarin Sodium. The American Surgeon, 85(6), E295-E297.
• Baker, C. L., Dhamane, A. D., Rajpura, J., Mardekian, J., Dina, O., Russ, C., et al. (2019). Switching to Another Oral Anticoagulant and Drug Discontinuation Among Elderly Patients With Nonvalvular Atrial Fibrillation Treated With Different Direct Oral Anticoagulants. Clinical and Applied Thrombosis/Hemostasis, 25, 1076029619870249.
• Brown, J. D., Shewale, A. R., Dherange, P., Talbert, J. C. (2016). A comparison of oral anticoagulant use for atrial fibrillation in the pre-and post-DOAC eras. Drugs & aging, 33(6), 427-436.
• Chen, H., Tao, R., Zhao, H., Jiang, J., Yang, J. (2020). Prevention of venous thromboembolism in patients with cancer with direct oral anticoagulants: A systematic review and meta-analysis. Medicine (Baltimore), 99(5).
• Costa, B. P., Manso, C., Baldaia, C., Alves, F., Sousa, F. (2000). Gastric pseudotumor. Hepato-gastroenterology, 47(31), 151. Cowell, R. P. (2014). Direct oral anticoagulants: integration into clinical practice. Postgraduate Medical Journal, 90(1067), 529-539.
• Deitelzweig, S., Luo, X., Gupta, K., Trocio, J., Mardekian, J., Curtice, T., et al. (2017). Comparison of effectiveness and safety of treatment with apixaban vs. other oral anticoagulants among elderly nonvalvular atrial fibrillation patients. Current medical research and opinion, 33(10), 1745-1754.
• Gómez-Outes, A., Luisa Suarez-Gea, M., Calvo-Rojas, G., Lecumberri, R., Rocha, E., Pozo-Hernández, C., et al. (2012). Discovery of anticoagulant drugs: a historical perspective. Current drug discovery technologies, 9(2), 83-104.
• Kang, E. A., Han, S. J., Chun, J., Lee, H. J., Chung, H., Im, J. P., et al. (2019). Clinical features and outcomes in spontaneous intramural small bowel hematoma: Cohort study and literature review. Intest Res, 17(1), 135-143. doi: 10.5217/ir.2018.00085
• Kones, O., Dural, A. C., Gonenc, M., Karabulut, M., Akarsu, C., Gok, I., et al. (2013). Intramural hematomas of the gastrointestinal system: a 5-year single center experience. J Korean Surg Soc, 85(2), 58-62. doi: 10.4174/jkss.2013.85.2.58
• evine, M. N., Raskob, G., Beyth, R. J., Kearon, C., Schulman, S. (2004). Hemorrhagic complications of anticoagulant treatment: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 126(3), 287S-310S.
• Mekaj, Y. H., Mekaj, A. Y., Duci, S. B., Miftari, E. I. (2015). New oral anticoagulants: their advantages and disadvantages compared with vitamin K antagonists in the prevention and treatment of patients with thromboembolic events. Therapeutics and clinical risk management, 11, 967.
• Millogo, G. R. C., Kologo, J. K., Kinda, G., Yaméogo, N. V., Tougma, J. B., Kambiré, Y., et al. Samadoulougou, A. (2018). Les accidents du traitement anticoagulant dans le Service de Cardiologie du Centre Hospitalier Universitaire Yalgado Ouedraogo de Ouagadougou (Burkina Faso). Pan African Medical Journal, 29.
• Panduranga, P., Al-Mukhaini, M., Al-Muslahi, M., Haque, M. A., Shehab, A. (2012). Management dilemmas in patients with mechanical heart valves and warfarin-induced major bleeding. World journal of cardiology, 4(3), 54.
• Polat, C., Dervisoglu, A., Guven, H., Kaya, E., Malazgirt, Z., Danaci, M., Ozkan, K. (2003). Anticoagulant-induced intramural intestinal hematoma. The American Journal of Emergency Medicine, 21(3), 208-211. doi: 10.1016/s0735-6757(02)42258-9
• Saccullo, G., Bucko, A. M., van Veen, J. J., Makris, M. (2017). Why is it so difficult to show that prothrombin complex concentrates are superior to fresh-frozen plasma for warfarin reversal? Blood Transfusion, 15(3), 277.
• Steffel, J., Verhamme, P., Potpara, T. S., Albaladejo, P., Antz, M., Desteghe, L., et al. (2018). The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. European heart journal, 39(16), 1330-1393.
• Tseng, C. Y., Fan, J. S., Yang, S. C., Huang, H. H., Chen, J. D., Yen, D. H., Huang, C. I. (2010). Anticoagulant-induced intramural intestinal hemorrhage. Am J Emerg Med, 28(8), 937-940. doi: 10.1016/j.ajem.2009.08.002
• Vecchio, R., Cacciola, E., Figuera, M., Catalano, R., Giulla, G., Distefano, E. R., Intagliata, E. (2019). Idiopathic intramural hematoma of the right colon. A case report and review of the literature. Int J Surg Case Rep, 60, 16-20.
• Yoldas, T., Erol, V., Caliskan, C., Akgun, E., & Korkut, M. (2013). Spontaneous intestinal intramural hematoma: What to do and not to do. Ulus Cerrahi Derg, 29(2), 72-75. doi: 10.5152/UCD.2013.41
• Yu, W.-H., Feng, C., Han, T.-M., Ji, S.-X., Zhang, L., & Dai, Y.-Y. (2018). Surgically treated rare intestinal bleeding due to submucosal hematoma in a patient on oral anticoagulant therapy: a case report. Medicine (Baltimore), 97(46).