|Year : 2013 | Volume
| Issue : 1 | Page : 95-97
Spontaneous mesenteric hemorrhage
Karan V. S. Rana, Sunil V Panchabhai, Sridharan Srihari, Kundan Kharde
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India
|Date of Web Publication||14-Mar-2013|
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune
Source of Support: None, Conflict of Interest: None
Spontaneous intra-abdominal hemorrhage or abdominal apoplexy is an acute abdominal emergency which can exhibit a wide spectrum of clinical presentation. With the expanding avenues for anticoagulation therapy, this condition is becoming commoner. The association of this condition with antiplatelet therapy is less well established. We present a case of spontaneous mesenteric hematomas causing intestinal obstruction in a patient on antiplatelet therapy for ischemic heart disease. A review of etiology, clinical presentation and protocol of management is also presented. A high index of suspicion on the part of the clinician is essential to ensure a favorable outcome in this condition.
Keywords: Abdominal apoplexy, antiplatelet therapy, intestinal obstruction, spontaneous mesenteric hemorrhage
|How to cite this article:|
Rana KV, Panchabhai SV, Srihari S, Kharde K. Spontaneous mesenteric hemorrhage. Med J DY Patil Univ 2013;6:95-7
| Introduction|| |
Acute occult intra-abdominal haemorrhage is a rare occurrence. The most common situations in which this is encountered are trauma and coagulation defects. , Therapeutic anticoagulation has become an emerging risk factor. We describe a case of spontaneous mesenteric hemorrhage causing intestinal obstruction in a patient on antiplatelet therapy.
| Case Report|| |
Sixty five years old male patient presented with generalized abdominal pain and distension for 24 hours with absolute constipation for 12 hours. He was on antiplatelet therapy (Aspirin 325mg and Clopidogrel 75mg OD) for the last six months for ischemic heart disease. Physical examination revealed tachycardia, hypotension and tachypnea. Abdominal examination revealed generalized abdominal distension with tenderness, guarding and rigidity, maximum in the left side of the abdomen. Shifting dullness was present and bowel sounds were sluggish.
Haemogram revealed leucocytosis. X ray erect abdomen showed ground glass appearance and X ray chest did not reveal any pneumoperitoneum. USG abdomen was suggestive of dilated loops of small bowel and dilated sigmoid colon, with moderate amount of free fluid in the abdomen. CT scan with IV, oral and rectal contrast reported redundant sigmoid colon extending to the right iliac fossa, with dilated loops of small bowel and moderate hemoperitoneum.
Exploratory laparotomy revealed redundant sigmoid colon in the right iliac fossa, with moderate dilatation. There were multiple hematomas in the mesentery of the entire small bowel [Figure 1]. There was one large hematoma in the mesentery of the mid ileum, about 20cm proximal to ileocaecal junction, with active ooze [Figure 2]. Bowel loops were dilated proximal to this segment of ileum. Resection of the segment of ileum was done with end to end anastomosis. Sigmoidopexy was also done. Two units of fresh blood were transfused intraoperatively. Antiplatelet therapy was withheld after consultation with the physician.
Postoperatively, patient developed surgical site infection with full thickness dehiscence over a length of 3 cm in the cranial end of the wound. No active surgical intervention was done considering the age and comorbidity, and the wound was allowed to heal by secondary intention. Antiplatelet therapy was restarted after a week. The histopathology stated no vascular malformation or vasculitis. The wound healed well, and patient is currently asymptomatic on follow up after a year.
| Discussion|| |
Idiopathic spontaneous intraperitoneal hemorrhage (ISIH), a rare cause of non-traumatic intra-abdominal bleeding  is characterized by severe bleeding in the retroperitoneum or intraperitoneum.  Its clinical presentations depend on its location and the extent of bleeding.  Bleeding from small vessels is slow and limited. Such hematomas usually resolve spontaneously and go undetected.  Bleeding has also been reported from rupture of tumors of organs such as liver, kidney, and hepatic hemangiomas. 
Etiological factors include hypertension, arteriosclerosis, arterial malformation, inflammation, pancreatitis, amyloidosis of mesentery, anticoagulant therapy and bleeding diatheses. ,,, The incidence of haemorrhagic complications occurring in patients on oral anticoagulant therapy varies between 3% and 48% in reported series. The majority of significant complications are abdominal and include bleeding in the gut (lumen, wall, mesentery), retroperitoneal bleeding, bleeding into or from solid viscera, and abdominal wall haematoma.  Spontaneous intramural hematomas have been reported in association with oral anticoagulation therapy. 
Most of the reports of spontaneous hemorrhage have been linked to the use of heparin or coumarin derivatives. The etiological relationship between antiplatelet therapy and intraabdominal hemorrhage has been less established. Takeshi et al. reported a case of hemorrhage in the greater omentum in a patient on antiplatelet therapy.  Mesenteric hematoma has been described as a rare complication of laparoscopy. 
Patients can also have partial or complete intestinal obstruction , due to the extrinsic pressure effects of the mesenteric hematoma on the bowel, ischemia of the bowel or associated intramural bowel hematoma. 
CT scan is the investigation of choice in the absence of an obvious underlying condition such as pancreatitis, peptic ulcer disease or trauma, as CT scan helps to exclude differential diagnoses. In our case, CT scan revealed hemoperitoneum, but the site of the bleed could not be determined.
Selective visceral arteriography often comes to the rescue of the treating physician, especially if there is active bleeding.  It is of particular use in locating pseudo aneurysms in the visceral arteries. Transcatheter arterial embolisation is coming up in a big way in controlling hemorrhage from the mesenteric vessels. Once the bleeding is controlled, repeated clinical assessment and imaging studies are required to monitor the status of the involved segment of bowel. 
The treatment of the condition depends on the type of clinical presentation. Stable patients can be managed conservatively for the reason that no evidence of necrosis could be found in the segment of bowel affected by a mesenteric hematoma or an intramural hematoma and when the hematoma resolves, the bowel continues to function normally.  Surgery is reserved for those patients with severe hypovolemia, intestinal obstruction, diagnostic uncertainty and for clinically deteriorating patient placed on conservative management. To generalize, a policy of "masterly inactivity" or a "watchful waiting" can be optimal in cases where the diagnosis is certain, there is no evidence of active bleeding and there is no evidence of complications. This has to be substantiated by sequential imaging, preferably CT scan.
Following the surgery and complete recovery, the patient was restarted on antiplatelet therapy because cessation of antiplatelet therapy is often not justifiable, even for minor surgeries, as the vast number of adverse cardiovascular events occur in the period of cessation of antiplatelet drugs.
With the increasing use of therapeutic anticoagulation, spontaneous intraabdominal hemorrhage has to be a serious consideration in patients with acute abdominal pain, on anticoagulation. Considering the wide spectrum of clinical presentation described, a high index of suspicion is warranted in the early diagnosis of this condition. An optimal combination of watchful waiting and timely intervention is essential to ensure a good outcome in this abdominal emergency.
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[Figure 1], [Figure 2]