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 .