Case 59 - Small bowel intramural hemorrhage

Summary

Imaging description

Intramural hemorrhage in the small bowel results in segmental circumferential bowel wall thickening. Thickening of the small bowel wall has been defined as a wall thickness greater than 4 mm [1], although in practice most radiologists use expert judgment to make this diagnosis. The wall thickening is usually homogeneous and may be of visibly high density. There may be associated bowel obstruction, adjacent fat stranding, or bloody ascites (Figures 59.1 and 59.2) [2–5].

Importance

Intramural hemorrhage in the small bowel is rare, but should be included in the differential of segmental small bowel wall thickening. It may be confused with ischemia, angioedema, or strangulated obstruction, and since management of these conditions is quite different, optimal radiological evaluation is critical.

Typical clinical scenario

Supratherapeutic anticoagulation with coumadin is the single commonest reason for spontaneous or non-traumatic intramural hemorrhage in the bowel, accounting for 8 cases in one series of 13 such patients [4]. In the same study, small bowel obstruction was present in 11 (85%) patients. A single hematoma was present in 85% of patients, and multiple hematomas were present in 15%. The jejunum was the most common site of hematoma, followed by the ileum and duodenum. Most patients with intestinal intramural hemorrhage can be treated conservatively with a good outcome.