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Small bowel intramural hemorrhage

Case contributed by Dr Wasif Mohammed

Presentation

Known history of cardiac disease, presented with acute onset left iliac fossa pain and recurrent vomiting.

Patient Data

Age: 50 years
Gender: Female
CT

Multiphasic CECT Abdomen study

Prosthetic mitral valve and pace-maker leads seen in-situ.

Marked dilatation of the esophagus, stomach and duodenum is seen, leading up to a grossly abnormal jejunal loop. The bowel segments distal to this loop are almost completely collapsed suggesting partial small bowel obstruction.

There is mild luminal dilatation with gross circumferential wall thickening of a long segment of the proximal jejunum, notably showing uniform thickening and close approximation of the bowel folds, consistent with the 'stack of coins' appearance. There is also prominence of the related mesenteric vessels and the lymph nodes. Subtle intramural hyperdensity is seen within the walls of the abnormal segment on the non-contrast images which likely denotes hemorrhage.

No filling defects seen in the superior mesenteric artery or the vein to indicate possible thrombosis. 

Case Discussion

This patient  had a known cardiac history and was on Warfarin. She presented with acute onset severe abdominal pain and signs of bowel obstruction. 

The CT findings demonstrate smooth uniform thickening along with close approximation of small bowel folds within a long segment of the proximal jejunum, giving the 'stack of coins' appearance. This is consistent with a diagnosis intramural hemorrhage secondary to anticoagulant therapy.

The differential for this appearance includes the Hidebound sign of systemic sclerosis, which refers to the appearance of tightly packed valvulae conniventes without significant thickening of the bowel wall. 

There is no follow up imaging available.

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