Idiopathic intramural hematoma of the right colon. A case report and review of the literature

Spontaneous mesenteric hematoma occurring during antithrombotic therapy and responsive to surgical treatment: a case report

BACKGROUND

Spontaneous mesenteric hematoma is a rare condition that is diagnosed when clinical and pathological findings do not identify an obvious causative disease. Various treatment options for spontaneous mesenteric hematoma exist; however, there are no clear treatment criteria. Herein, we report a case of spontaneous mesenteric hematoma that was successfully treated surgically and discuss the optimum treatment strategy based on similar cases.

CASE PRESENTATION

A 63-year-old man with abdominal persisting for 3 days presented to our hospital after going into shock without any triggers. The patient had a history of atrial fibrillation, stroke, and an aneurysm, and was receiving antithrombotic therapy. Abdominal contrast-enhanced computed tomography revealed a mass structure within the sigmoid mesentery, which was suspected to be a hematoma. The patient was admitted to the hospital for follow-up observation after initial infusion and vital stabilization. However, the following day, the patient developed acute generalized peritonitis with necrosis of the sigmoid colon; therefore, emergency Hartmann's surgery was performed. Intraoperative and histopathological examinations revealed no evidence of bleeding.

CONCLUSION

Spontaneous mesenteric hematomas tend to be associated with intestinal necrosis and may require surgical treatment with bowel resection owing to the difficulty in identifying the responsible vessel. Moreover, our results suggest that the presence of antithrombotic therapy may be an important factor affecting spontaneous mesenteric hematoma development.

A Case of Direct-Acting Oral Anticoagulant-Induced Intramural Colon Hematoma Successfully Treated by Laparoscopic Surgery

Intramural intestinal hematoma is a rare disease, one of the triggering factors of which is the use of anticoagulants. In previous reports, most patients were on treatment with warfarin. Herein, we report a case of direct-acting oral anticoagulant (DOAC)-induced intramural hematoma of the ascending colon in a patient refractory to conservative treatment and required laparoscopic right hemicolectomy. An 80-year-old male patient with a history of atrial fibrillation and cerebral infarction, on treatment with apixaban, was brought to our hospital with the chief complaints of abdominal pain, vomiting, and melena. Imaging revealed the cause of symptoms to be intestinal obstruction caused by a mass lesion on the wall of the ascending colon. We initially opted for conservative treatment with discontinuation of apixaban and insertion of an ileus tube. Intestinal dilatation findings showed improvement; however, subsequent imaging examinations did not reveal the shrinkage of a lesion in the ascending colon. If the mass was not removed, recurrence of bowel obstruction symptoms was expected, so we decided to perform surgical intervention. A laparoscopic right hemicolectomy was performed, and an intramural hematoma of the ascending colon was diagnosed based on the excised specimen. He needed a blood transfusion for anemia but was discharged on postoperative day 14 with no other complications. DOACs are now widely used in patients with atrial fibrillation, and the risk of bleeding as a side effect is extremely low compared to conventional anticoagulants, including warfarin. However, when abdominal pain occurs, as in the present case, an intramural hematoma should be considered in the differential diagnosis. There is no established treatment plan for intestinal intramural hematoma. Although conservative treatment is effective in some cases, it is difficult to evaluate the risk of bleeding associated with DOACs using coagulation tests. Even if conservative treatment is selected, it is essential to determine surgical resection, if necessary, based on the clinical course and imaging and blood test findings.

Systemic AL amyloidosis with multiple submucosal hematomas of the colon: a case report and literature review

Amyloid light-chain (AL) amyloidosis rarely causes colorectal submucosal hematoma. A 76-year-old man presented with a complaint of bloody stool. An initial colonoscopy revealed ulcerative lesions in the descending colon, leading to a diagnosis of ischemic colitis. One month later, he presented with cardiac failure, suspected cardiac amyloidosis, and underwent a second colonoscopy. Although it revealed multiple ulcerative lesions from the ascending to transverse colon, biopsy samples did not confirm amyloid deposition. He underwent a third colonoscopy 3 weeks later due to recurrent bloody stool. It showed multiple submucosal hematomas from the ascending to descending colon concomitant with ulcerative lesions in the descending colon and multiple elevated lesions in the sigmoid colon. Biopsy samples confirmed amyloid deposition. Using a systemic search, multiple myeloma with AL amyloidosis was diagnosed. Colorectal submucosal or intramural hematomas are conditions usually encountered in trauma, antithrombotic use, or coagulation disorders. Based on our review of the literatures, we identified several differences between colorectal intramural hematoma caused by amyloidosis and those caused by other etiologies. We believe that amyloidosis should be considered when relatively small and multiple colorectal hematomas, not restricted to the sigmoid colon, and with concomitant findings of erosions and ulcers, are observed.

A Rare Case of Traumatic Colonic Intramural Hematoma in Saudi Arabia

Colonic intramural hematomas are rarely encountered clinically. They are most commonly caused by blunt trauma to the abdomen. Diagnosis is usually reached by a combination of a detailed history, physical examination, and radiological investigations. A 14-year-old female patient presented to the emergency department complaining of abdominal pain with a history of a go-karting accident. Upon physical examination, the patient was tachycardic and hypertensive, with right-side abdominal tenderness and fullness. After going through routine radiological investigations, a computed tomography scan showed a large intramural hematoma of the ascending colon measuring around 7.7 x 8.4 x 2 cm. The patient was admitted for conservative management. Throughout her admission, serial examinations were performed, which showed improvement in the patient's condition and the size of the hematoma. The patient was discharged in a stable condition after showing good recovery. Following up with the patient a month later, she was in good condition with no active complaints, and an ultrasound was done that revealed complete resolution. To our understanding, this report of colonic intramural hematoma caused by the unusual etiology of the go-karting accident, which was successfully managed conservatively, adds significantly to the literature.

A Case of Idiopathic Colonic Intramural Hematoma: Successful Expectant Management

Intramural gastrointestinal hematomas are commonly observed following abdominal trauma or are associated with coagulopathy disorders. In contrast, idiopathic gastrointestinal hematoma is rare, and colonic involvement is sporadic, with very few published reports. We report the case of a 29-year-old female who presented with right hypogastric pain over the last three days. Abdominal CT with contrast revealed an 8.5 × 6 × 7.5 cm pre-occlusive intramural hematoma of the ascending colon up to the hepatic flexure with diffuse edematous wall thickening, indicating colonic obstruction. On colonoscopy, the site of the intramural hematoma was identified without active bleeding or obvious pathology, and the colonoscope successfully passed through the region. The patient was managed conservatively. A month later, abdominal CT revealed complete resolution of the colonic hematoma. After two months of follow-up, the patient was free from gastrointestinal symptoms. In conclusion, idiopathic colon intramural hematoma is rare, with a challenge in diagnosis and treatment; efforts should be made to treat it with conservative therapy.

Hemorrhagic shock due to ruptured idiopathic intramural hematoma of the sigmoid colon-An autopsy case report

We describe herein an autopsy case involving fatal hemorrhagic shock due to idiopathic sigmoid colonic intramural hematoma rupturing into the abdominal cavity. Antemortem computed tomography revealed a mass lesion in the sigmoid colon and a large amount of hemoperitoneum. On forensic autopsy, intramural hematoma of the sigmoid colon with ruptured serosa was identified, while the mucosa remained intact. Microscopically, hematomas were apparent, mainly in the muscularis propria. We diagnosed the cause of death as hemorrhagic shock due to idiopathic intramural hematoma of the sigmoid colon rupturing into the abdominal cavity. Although the patient had been receiving peritoneal dialysis, no relationship was identified between dialysis catheters and sigmoid colon intramural hematoma rupture. On computed tomography, the mass lesion was initially considered a submucosal neoplastic lesion or endometriotic lesion. Intramural hematoma should be considered as a differential diagnosis.

Giant Proximal Right Colon Submucosal Hematoma Leading to a Large Bowel Obstruction

A 41-year-old female with a previous history of chronic obstructive pulmonary disease (COPD) and polycythemia presented to the emergency department with worsening shortness of breath and cough which progressed to respiratory distress requiring mechanical ventilation. During her hospital stay, she developed abdominal distention followed by a fever and a four-point decrease in hemoglobin. A non-contrasted abdominopelvic CT scan was ordered which showed a very large retroperitoneal hematoma adjacent to the right colon with subtle active bleeding. Selective angioembolization of a distal segment of the right colic artery was performed by Interventional Radiology (IR) to achieve hemostasis and hemodynamic stability. Due to the persistent and worsening abdominal distention, a CT scan with contrast was ordered which clearly showed a submucosal hematoma in the region of the right colon extending from the hepatic flexure to the cecum. The hematoma was completely obstructing the proximal and mid ascending colon leading to a large bowel obstruction. Exploration of the abdomen showed severe bowel dilation, and frank ischemia of the hepatic flexure of the colon. Right hemicolectomy with primary ileocolonic anastomosis to evacuate the right retroperitoneal hematoma was subsequently performed. The patient was discharged on post-operative day 16 with no major complications.

Perspectives and Management Strategies for Acute Colonic Intramural Hematoma

Acute intramural hematoma of the colon is a rarely encountered clinical condition with diverse precipitating factors. Different acute and chronic complications emerge following hematoma formation, mandating high clinical suspicion for early diagnosis and optimum management. CECT represents the cornerstone for the proper demonstration of colonic hematomas and possible detection of complications as well as the underlying etiology. There are multiple strategies for management of intramural hematoma and treatment should be tailored according to the etiology and the clinical condition of the patient, reserving surgical intervention for unstable or complicated cases. Endoscopic management of colonic hematomas offers a promising minimally invasive modality with potential safety and efficacy.

Spontaneous descending colon hematoma due to a rare complication of warfarin therapy: A case report

Intramural hematoma of the colon should be considered as a diagnosis in anticoagulated patients who present with prolonged INR and GI symptoms. In stable cases, conservative medical treatment can be sufficient to avoid unnecessary procedures.

Delayed presentation of intramural cecal hematoma with challenges in the treatment. A case report and review of the literature

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Intramural cecal hematoma is a rare condition with only 14 reported cases.

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It can mimic acute appendicitis.

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A history of trauma, if present, may offer a pointer to the diagnosis.

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Conservative treatment is the first choice in management. However, surgery still has a role.

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Evacuation of cecal hematoma can preserve the colon in selected patients.

Introduction

Intramural cecal hematomas are rarely encountered clinical entities with only 14 cases reported in our literature. It is usually reported after blunt external trauma, endoscopy-related trauma, coagulopathies, and occasionally spontaneous. Most cases presented acutely after primary insult; however, a delayed presentation rarely can occur.

Case presentation

Herein we describe an 8-year-old male patient who presented to the emergency department with an appendicitis-like picture six weeks after a history of falling. Intraoperatively, the patient was found to have a normal appendix. However, a large intramural cecal hematoma contains black blood with many clots was found. The patient was treated by hematoma evacuation with preservation of the cecum and colon and he was discharged with uneventful recovery. During two years follow up there was no history of complications or recurrence.

Discussion

Intramural cecal hematoma could be presented with various symptoms that range from mild abdominal pain to severe abdominal pain with vomiting, intestinal obstruction, bowel perforation, and hemoperitoneum. Diagnosis is challenging, and CT scan is the key for diagnosis. Although Conservative therapy is the first-line treatment; however, surgery still has a role in selected cases.

Conclusion

The authors report the first case of cecal hematomas with a delayed presentation. The optimal treatment should be individualized according to different etiologies, the patient's stability, and the presence of complications.

Traumatic Acute Colonic Intramural Hematoma: A Rare Entity and Successful Expectant Approach

Acute intramural hematoma in colon is a rare presentation following trauma. There are reports in literature of acute colonic hematoma following trauma, warfarin intake and in patient with coagulation disorders. In traumatic acute colonic intramural hematoma, most of the reported cases were managed surgically. Very few cases were successfully managed conservatively. We present a case of 28-year-old male who presented to the surgical emergency after two days of road traffic accident. After relevant investigations, he was found to have intramural hematoma of ascending colon, which was managed conservatively.