for those patients presenting with symptoms of small - bowel obstruction , the list of differential diagnoses is vast , with numerous extramural , mural and luminal causes . in this report
, we describe two cases that presented with a history and imaging suggestive of small - bowel obstruction . both had deranged clotting function as a result of excess anticoagulation .
we present their subsequent management and emphasize the merit of conservative management for this rare cause of small - bowel obstruction .
the first case we report is of a 62-year - old lady with a background of atrial fibrillation , hypertension and chronic obstructive pulmonary disease , who presented with a 2-day history of abdominal pain , distension and vomiting of bilious fluid .
she had not passed stools or flatus . on examination she appeared uncomfortable , with an irregular pulse rate of 144 , but she was maintaining her blood pressure at 116/70 mmhg .
on palpation , her abdomen was distended with generalized tenderness ; she was maximally tender in the left iliac fossa .
laboratory investigations revealed an international normalized ratio ( inr ) of 10 ; she was anticoagulated with warfarin due to her atrial fibrillation .
initial imaging revealed dilated small - bowel loops on abdominal radiograph ( fig .  1 ) . 

a ct scan was performed that showed dilation of the proximal small bowel , with a long segment of thickened small - bowel loops that was reported as possible intussusception ( fig .  2 ) .
the images were discussed further at the multidisciplinary surgical radiology meeting in the context of her haematology results .
it was determined that the long segment of the thickened small bowel was , in fact , haemorrhage rather than intussusception . 

figure  2:post - contrast ct ( sagittal plane ) showing proximal small - bowel dilation and a thickened small - bowel segment ( case 1 ) .
post - contrast ct ( sagittal plane ) showing proximal small - bowel dilation and a thickened small - bowel segment ( case 1 ) .
the patient was managed conservatively with intravenous fluids , a nasogastric tube and bowel rest .
her warfarin was withheld and her anticoagulation was reversed with fresh frozen plasma and vitamin k over the course of 4 days .
she improved clinically and tolerated oral intake with the passage of stool . a small - bowel meal 4 days after admission revealed no residual evidence of obstruction and she was discharged home .
the second case described is of a 57-year - old gentleman who presented with a 3-day history of abdominal pain , vomiting and absolute constipation .
his past medical history of note was a metallic aortic valve , although he was unable to give an accurate drug history on admission . on examination ,
3 ) , and he was managed as a case of small - bowel obstruction , with intravenous fluid and a nasogastric tube . 
 figure  3:abdominal radiograph showing dilated small - bowel loops ( case 2 ) . abdominal radiograph showing dilated small - bowel loops ( case 2 ) .
the following morning on the post - take ward round he was peritonitic and a decision was made to take him for an exploratory laparotomy prior to further imaging .
an inr was sent as a work - up for theatre , which returned at 12.6 ; drug reconciliation revealed that he was on warfarin .
intraoperatively , there was a 30-cm segment of proximal jejunum with spontaneous intramural haemorrhage ; the bowel was viable with pulsatile vessels in the mesentery .
there was no intraluminal bleeding or any other cause for obstruction ; therefore , washout and closure was performed without resection .
postoperatively , he recovered well and was discharged on clexane , with the view to restarting warfarin in the community .
the first case we report is of a 62-year - old lady with a background of atrial fibrillation , hypertension and chronic obstructive pulmonary disease , who presented with a 2-day history of abdominal pain , distension and vomiting of bilious fluid .
she had not passed stools or flatus . on examination she appeared uncomfortable , with an irregular pulse rate of 144 , but she was maintaining her blood pressure at 116/70 mmhg .
on palpation , her abdomen was distended with generalized tenderness ; she was maximally tender in the left iliac fossa .
laboratory investigations revealed an international normalized ratio ( inr ) of 10 ; she was anticoagulated with warfarin due to her atrial fibrillation .
initial imaging revealed dilated small - bowel loops on abdominal radiograph ( fig .  1 ) . 

a ct scan was performed that showed dilation of the proximal small bowel , with a long segment of thickened small - bowel loops that was reported as possible intussusception ( fig .  2 ) .
the images were discussed further at the multidisciplinary surgical radiology meeting in the context of her haematology results .
it was determined that the long segment of the thickened small bowel was , in fact , haemorrhage rather than intussusception . 

figure  2:post - contrast ct ( sagittal plane ) showing proximal small - bowel dilation and a thickened small - bowel segment ( case 1 ) .
post - contrast ct ( sagittal plane ) showing proximal small - bowel dilation and a thickened small - bowel segment ( case 1 ) .
the patient was managed conservatively with intravenous fluids , a nasogastric tube and bowel rest .
her warfarin was withheld and her anticoagulation was reversed with fresh frozen plasma and vitamin k over the course of 4 days .
she improved clinically and tolerated oral intake with the passage of stool . a small - bowel meal 4 days after admission revealed no residual evidence of obstruction and she was discharged home .
the second case described is of a 57-year - old gentleman who presented with a 3-day history of abdominal pain , vomiting and absolute constipation .
his past medical history of note was a metallic aortic valve , although he was unable to give an accurate drug history on admission . on examination ,
3 ) , and he was managed as a case of small - bowel obstruction , with intravenous fluid and a nasogastric tube . 
 figure  3:abdominal radiograph showing dilated small - bowel loops ( case 2 ) .
the following morning on the post - take ward round he was peritonitic and a decision was made to take him for an exploratory laparotomy prior to further imaging .
an inr was sent as a work - up for theatre , which returned at 12.6 ; drug reconciliation revealed that he was on warfarin .
intraoperatively , there was a 30-cm segment of proximal jejunum with spontaneous intramural haemorrhage ; the bowel was viable with pulsatile vessels in the mesentery .
there was no intraluminal bleeding or any other cause for obstruction ; therefore , washout and closure was performed without resection .
postoperatively , he recovered well and was discharged on clexane , with the view to restarting warfarin in the community .
spontaneous intramural haemorrhage is characterized by bleeding into the submucosal layer of the bowel in the absence of trauma .
the jejunum is the most commonly affected site , followed by the ileum and then duodenum .
this is in contrast to traumatic intramural haemorrhage primarily seen in the duodenum due to its retroperitoneal components .
it occurs during a hypercoagulable state , excess anticoagulation due to warfarin therapy being the most frequent aetiology , but case reports also describe such a presentation in those with haemophilia , haematological malignancies and chemotherapy treatment .
the symptoms are indistinguishable from other causes of small - bowel obstruction , although there may be a history of warfarin therapy or peripheral stigmata of excess anticoagulation .
a contrast ct scan of the abdomen and pelvis is the imaging modality of choice , classically showing circumferential hyperdensity and wall thickening , with luminal narrowing and obstruction .
the management of small - bowel obstruction secondary to intramural haemorrhage is predominantly conservative , including reversal of clotting factors .
operative management may be indicated if diagnostic uncertainty remains or there is haemodynamic instability due to active bleeding .
abbas et al . presented data from 13 cases of spontaneous intramural small - bowel haemorrhage , retrospectively analysed with regard to inpatient outcomes and long - term morbidity .
eleven of the 13 patients were managed conservatively with no significant sequelae at a mean follow - up of 35 months ; the two patients who underwent laparotomy had a viable small bowel and no resections were undertaken . in an aging population , with a large number of patients anticoagulated for medical conditions such as atrial fibrillation , spontaneous intramural haemorrhage is a differential that must be considered .
identification of hyperdense intramural bleeding , in the context of grossly deranged clotting , may avoid the morbidity of undergoing a potentially unnecessary laparotomy .
 spontaneous intramural haemorrhage is a rare cause of small - bowel obstruction , occurring most commonly in those who are anticoagulated . 
 we describe two cases that presented with a history and imaging suggestive of small - bowel obstruction ; both had international normalized ratios of above 10 on admission . 
 the first case , a 62-year - old lady on warfarin for atrial fibrillation , was managed conservatively with good effect . 
 in contrast , the second case , a 57-year - old gentleman on warfarin for his metallic aortic valve , underwent diagnostic laparotomy that revealed a 30-cm segment of proximal jejunum with spontaneous intramural haemorrhage . in this study , we emphasize the merit of conservative management for this rare cause of small - bowel obstruction . 
INTRODUCTION
CASE REPORT
Case 1
Case 2
DISCUSSION
CONFLICT OF INTEREST STATEMENT