Gastro Intestinal Intramural Hematomas Versus Mesenteric Ischaemia- Clinico-Radiological Profile
Sudhindran Surendran*1, Unnikrishnan Gopalakrishnan1, Dayananda Lingegowda2, Sudheer Othiyil Vayoth1, Puneet Dhar1
1Gastro Intestinal Surgery, Amrita institute of medical Sciences, Kochi, India; 2radiology, Amrita institute of medical Sciences, Kochi, India
Aim: Gastro intestinal(GI) Intramural bleeds, secondary to anticoagulation often mimic Mesenteric Ischemia.Whilst intramural bleeds can be conservatively managed, mesenteric ischaemia requires active intervention.Aim of the study was to analyze characteristics of patients presenting with GI intramural hematomas to help evolve guidelines based on clinical and imaging features to differentiate them from mesenteric ischemia.
Methods: Clinico-radiological features of all GI Intramural Hematomas diagnosed between 2000-2006 (Group 1=8) were compared with a group of surgically confirmed mesenteric ischemias in the same period (Group 2=27)by retrospective analysis of database.
Results: All patients in Group 1 were on anticoagulation for cardiac co-morbidities. All underwent CT abdomen with plain and IV contrast aimed for venous phase.The first patient in Group I underwent an exploratory laparotomy and small bowel resection, due to suspicion of mesenteric ischaemia. The histopathology showed extensive hemorrhage with no evidence of ischaemia. The subsequent seven patients were suspected to have intramural bleeds and were managed conservatively with stabilization of INR.Clinical and imaging features of the two groups are given in Tables 1 and 2
Conclusions: Anticoagulant therapy with rectal bleeding often suggest the possibility of GI Intramural hematoma. On CT scan - proximal location, increased wall thickness, hyper density on plain scan and contrast enhancement of mucosa were suggestive of mural hematoma. In such cases, a conservative approach maybe appropriate, albeit exercising a low threshold for laparotomy, given the differential diagnosis of mesenteric ischaemia
Imaging Features
| Charectersetic | Group I (n=8) | Grup II (n=27) | P value |
| Proximal Site | 6 | 3 | 0.002 |
| Short segment | 7 | 13 | 0.6 |
| Thockness(mm) | 17±4 | 8±3 | 0.001 |
| Hounsefield Units | 65±14 | 34±6 | 0.001 |
| fat stranding | 4 | 15 | 0.8 |
| ascites | 6 | 18 | 0.3 |
| mucosal enhancement | 6 | 11 | 0.01 |
| dilatation | 3 | 12 | 0.7 |
clinical features
| characteristics | Group I (n=8) | Group II (n=27) | P value |
| age | 54±13 | 49±14 | 0.3 |
| pain | 8 | 23 | 0.2 |
| vomiting | 7 | 17 | 0.2 |
| peripheral vascular disease | 0 | 6 | 0.143 |
| rectal bleed | 3 | 2 | 0.03 |
| anticoagulation | 8 | 12 | 0.005 |
| INR over 3 | 7 | 22 | 0.001 |
