Surgery question

[sozme]

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Evidently the answer is C (which I did guess correctly). However, I was wondering how it was possible to have an intramural hematoma in the small bowel yet have a NEGATIVE stool occult blood? I was thinking intramural meant inside the lumen, but now I am wondering if it means between layers of the bowel wall such that no blood is actually getting into the lumen... do I have this correct?

Also trying to understand why the some of the other answers are wrong. I never considered D or E, but why not A or B? I figured she had been off warfarin for 1 day and had an INR of 6 the day before, so that made B less likely, but my hold up again was this thing with the occult blood.

 

[Missorleans]

Intramural means within the wall. The hematoma compresses the lumen of the proximal small bowel, causing the nausea and vomiting, like an SBO. However, I'm not sure why she would have a hematoma in the first place, the only other questions I've seen about that they have a history of blunt abdominal trauma. Maybe it's from the INR of 6.
A would also cause an SBO, but wouldn't explain the drop in hemoglobin.
B is a good choice in a patient with a fib but it appears she wasn't subtherapeutic on her warfarin.

 

[1badvette]

http://www.medscape.org/viewarticle/772205_3