Differential Diagnosis for Abdominal Pain and Vomiting

The patient's presentation of abdominal pain, persistent vomiting, and a significant drop in hemoglobin level, along with a recent history of anticoagulation with warfarin, suggests a hemorrhagic or ischemic event. The differential diagnoses can be categorized as follows:

• Single Most Likely Diagnosis

  • C) Intramural hematoma of the proximal small bowel: This condition is highly plausible given the patient's recent anticoagulation therapy with warfarin, which was discontinued due to an elevated INR of 6. The symptoms of abdominal pain, vomiting, and a significant decrease in hemoglobin level are consistent with an intramural hematoma causing bowel obstruction or bleeding.

• Other Likely Diagnoses

  • B) Intestinal ischemia from a cardiac embolus: Although the patient was recently cardioverted for atrial fibrillation and started on warfarin, the risk of a cardiac embolus cannot be entirely ruled out, especially if the anticoagulation was not fully effective at the time of the event. However, the absence of a clear embolic source and the recent normalization of the heart rhythm make this less likely.
  • A) Internal small-bowel herniation: This could be a cause of bowel obstruction and ischemia, but it would not directly explain the significant drop in hemoglobin unless there was associated bowel infarction.

• Do Not Miss Diagnoses

  • D) Intussusception of the small bowel: Although less common in adults, intussusception can cause bowel obstruction and ischemia, leading to severe abdominal pain and vomiting. It is crucial to consider this diagnosis due to its potential for severe complications if not promptly treated.
  • E) Malrotation of the small bowel: This congenital anomaly can present at any age, especially if there is an associated volvulus or obstruction. It is essential to consider this diagnosis due to its potential for severe complications, including bowel ischemia.

• Rare Diagnoses

  • Other rare causes of abdominal pain and vomiting, such as mesenteric venous thrombosis or arteriovenous malformations, could be considered but are less likely given the patient's presentation and recent medical history. These conditions might not directly relate to the patient's anticoagulation therapy or recent cardioversion but should be kept in mind if initial diagnoses are ruled out.