Clinical features of our patients with spontaneous intramural intestinal hematoma and the use of direct oral anticoagulants in the maintenance therapy

Yıl 2020, Cilt: 3 Sayı: 3, 201 - 213, 29.12.2020

Cem Karaali , Semra Demirli Atıcı , İsmail Sert , Korhan Tuncer , Mehmet Üstün , Kenan Teker , Mustafa Emiroğlu

Öz

Aim: Spontaneous intramural intestinal hematoma (SIIH) is a rare complication in patients receiving anticoagulant therapy and usually occurs secondary to warfarin use.
In our study, the clinical characteristics and treatment approaches of SIIH cases will be examined. In addition, our study will share the long-term follow-up’s of SIIH patients who have been shifted to direct oral anticoagulants (DOACs) instead of warfarin as a maintenance treatment for the first time in the literature.
Material and Methods: The data of 21 patients with a diagnosis of SIIH associated with warfarin use between 2015 and 2020 were retrospectively analyzed.
Results: The average age of the patients included in the study was 67.6 ± 12.0 (range: 45-90), 9 of them were female and 12 were male. All of the patients were using warfarin for various diseases. While the most common complaint was abdominal pain, in the physical examination of all patients, abdominal tenderness was detected. In all patients, the INR value was above the therapeutic values ​​at the time of arrival at hospital, and 14 patients had anemia. Abdominal computed tomography (CT) helped diagnose SIIH in all patients. While 18 patients were treated conservatively, 3 patients were operated. One of the operated patients died due to the postoperative pulmonary embolism. While 7 (35%) patients continued with warfarin after discharge, 13 (65%) patients were replaced with DOAC medications. While the mean follow-up period of patients using warfarin is 22.1 ± 18.2 months (range: 8-61), those using DOAC is 26.4 ± 19.3 (range: 6-55) months. During follow-up, no recurrence of SIIH was observed in either group.
Conclusion: In patients using oral anticoagulants, and especially with abdominal pain and elevated INR values, SIIH should be considered among the differential diagnoses. In the treatment of SIIH, firstly, medical treatment options should be tried, but the operation should not be avoided in patients with hemodynamic impairment, acute abdominal findings, or patients who cannot be diagnosed differentially. In addition, DOAC drugs may be considered as an alternative to warfarin in maintenance therapy after SIIH in selected patient groups.

Anahtar Kelimeler

Anticoagulant, direct oral anticoagulant drug, small intestine

Destekleyen Kurum

Yok

Proje Numarası

Approval from the institutional research ethics board was obtained (decision number 2020/8-7)

Teşekkür

We thank all general surgery department staff for their cooperation.

Spontan intramural intestinal hematomlu hastalarımızın klinik özellikleri ve idame tedavisinde direkt oral antikoagulanların kullanımı

Öz

Amaç: Spontan intramural intestinal hematomlar (SIIH), antikoagulan tedavi alan hastalarda nadir görülen bir komplikasyondur ve genellikle warfarin kullanımına sekonder olarak ortaya çıkar. Çalışmamızda, SIIH olgularının klinik karakteristikleri ve tedavi yaklaşımları incelenecektir. Ayrıca çalışmamız, literatürde ilk kez idame tedavisi olarak warfarin yerine direkt oral antikoagulan(DOAC)’lara çevrilmiş SIIH hastalarının uzun dönem takiplerini de paylaşacaktır.

Yöntem ve Gereçler: 2015-2020 yıllarında warfarin kullanımına bağlı SIIH tanısıyla yatan 21 hastanın verisi retrospektif olarak incelendi.

Bulgular: Çalışmaya alınan hastaların yaş ortalaması 67.6±12.0 (range: 45-90) olup, 9’u kadın 12’si erkek idi. Hastaların tümü çeşitli hastalıklar için warfarin kullanmakta idi. En sık başvuru yakınması karın ağrısı iken, tüm hastaların fizik muayenesinde karında hassasiyet saptandı. Hastaların hepsinde başvuru anında INR değeri terapotik değerlerin üstünde olup, 14 hastada anemi saptanmıştır. Abdomen bilgisayarlı tomografi (BT) hastaların hepsinde SIIH tanısı koymada yardımcı olmuştur. 18 hasta konservatif olarak tedavi edilirken, 3 hastaya operasyon uygulandı. Opere edilen hastalardan birinde postoperatif pulmoner emboli gelişimine bağlı mortalite gelişmiştir. 7 (35%) hastanın taburculuk sonrası tedavisine warfarin ile devam edilmiş iken, 13 (65%) hastanın tedavisi DOAC ilaçlar ile değiştirilmiştir. Warfarin kullanan hastaların takip süresi ortalama 22.1±18.2 ay (range: 8-61) iken, DOAC kullanan hastalarınki 26.4±19.3 (range: 6-55) aydır. Takipte her iki grupta da SIIH nüksü görülmedi.

Tartışma ve Sonuç: Oral antikoagulan kullanan ve özellikle de INR değerleri (seviyeleri) yükselmiş karın ağrılı hastalarda, SIIH ayırıcı tanılar arasında düşünülmelidir. SIIH’lerin tedavisinde öncelikle medikal tedavi seçenekleri denenmeli ancak hemodinamisi bozulan, akut karın bulguları olan ya da ayırıcı tanısı yapılamayan hastalarda ise operasyondan kaçınılmamalıdır. Ayrıca seçilmiş hasta gruplarında SIIH sonrası idame tedavisinde DOAC ilaçlar warfarin’e bir alternatif olarak düşünülebilir.

Anahtar Kelimeler

Antikoagulan, direkt oral antikoagulan, ince bağırsak

Proje Numarası

Approval from the institutional research ethics board was obtained (decision number 2020/8-7)

Kaynakça

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