Spontaneous perforation of an intramural rectal hematoma: Report of a case

A case of gastrointestinal perforation following transarterial embolization for an intramural hematoma after cold snare polypectomy of an adenoma in the transverse colon

We encountered a case of a large hematoma developing with perforation shortly after a cold snare polypectomy for a colorectal adenoma. The patient underwent cold snare polypectomy for a 3-mm type Is lesion in the transverse colon at another facility. Two hours later, she visited the emergency room due to abdominal pain. Contrast-enhanced computed tomography revealed a 70 mm, high-intensity mass in the transverse colon with contrast extravasation. We attempted transcatheter arterial embolization to stop the bleeding. Several hours later, the anemia had not worsened, but the severe abdominal pain persisted. Urgent laparoscopic right hemicolectomy was performed due to the possibility of gastrointestinal perforation. The surgery was successfully completed. Pathology reports confirmed the presence of an intramural hematoma in the proximal transverse colon with hemorrhagic infiltration of all layers, along with extensive ischemic changes. A perforation was identified in this area, with mucosal defects observed near the hole, possibly due to cold snare polypectomy.

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.

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

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A very rare case of spontaneous colon hematoma has been reported.

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The rarity of our case of colon hematoma is due to the fact that it is idiopathic.

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The topic is still under discussion in the Literature since the pathophysiology remains still unknown.

Introduction

Intestinal hematoma is usually observed after an abdominal trauma or in patients treated with anticoagulant therapy. Conversely, idiopathic bowel hematoma is very rare, being colon involvement sporadic with few reports in the Literature.

Presentation of case

The Authors report a case of idiopathic spontaneous large bowel hematoma. A 48-year-old man was admitted for a thoraco-abdominal pain and signs of acute abdomen and fever. After ruling out heart diseases, a CT scan revealed a marked thickening of the ascending colon wall, obstructing the bowel lumen. Leukocytosis was observed. In an emergency setting, an explorative laparotomy was performed. Hemoperitoneum and a large hematoma involving the caecum and the ascending colon were detected, together with intramesenteric and retroperitoneal blood effusion. A right hemicolectomy was accomplished. Histopathology confirmed the diagnosis of large bowel hematoma. Post-operative molecular diagnostic testing for coagulative disorders failed to demonstrate any genetic variation associate with hemorrhagic predisposition.

In the post-operative course, the patient experienced a left basal bronco-pneumonia with increased unilateral pleural effusion, successfully treated by a thoracic drain and antibiotic therapy.

Discussion

The reported case and Literature data show that diagnosis of idiopathic colon intramural hematoma is challenging, especially in the emergency setting. Although conservative therapy is the first line treatment, surgery still has an important role when the diagnosis is uncertain, medical treatment fails or a complication, such untreatable bleeding, perforation or occlusion occur.

Conclusion

The Authors report a very rare case of spontaneous intramural hematoma of the right colon. Surgery still has a role in selected cases.

Intramural duodenal hematoma: clinical course and imaging findings

Background

Intramural duodenal hematoma is a rare condition. Different imaging modalities are at hand for diagnosis.

Purpose

To identify patients with intramural duodenal hematoma and report imaging findings and clinical courses.

Material and Methods

Typical imaging patterns using ultrasound, computed tomography, and magnetic resonance imaging were carried out on 10 patients.

Results

The mean patient age was 7.5 years. The average disease duration was 13 months. Clinical signs of improvement were observed within 16 days. Residues were still detectable at long-term follow-up.

Conclusion

For patients with intramural duodenal wall hematoma, diagnosis should be considered early. Typical imaging findings should be known to ensure optimal treatment.

Surgically treated rare intestinal bleeding due to submucosal hematoma in a patient on oral anticoagulant therapy: A case report

RATIONALE

Bleeding in the gastrointestinal tract is a common complication of oral anticoagulant therapy (AT), and it usually appears as mucosal erosion or ulcer; however, intestinal submucosal hematoma (ISH) is an uncommon cause of hemorrhage.

PATIENT CONCERNS

This report presents the case of a 70-year-old woman with acute hematochezia induced by AT. She underwent computed tomography and endoscopy.

DIAGNOSES

Colon submucosal hematoma.

INTERVENTIONS

Conservative treatment had no effect, and the patient underwent emergency surgery.

OUTCOMES

Surgical resection showed hemorrhage and necrosis in the left colon, and the patient recovered 24 hours after surgery and continued AT.

LESSONS

The present case indicates that the ISH should be kept in mind as a complication of AT. It can be managed conservatively in some stable patients, but emergency surgery may be needed in some serious situations.

Colonic Perforation Secondary to Idiopathic Intramural Hemorrhage

Intramural colonic hemorrhage is rare and often secondary to trauma or anticoagulation therapy. Idiopathic intramural hemorrhages in the alimentary tract have rarely been reported. While several reports of spontaneous perforation of an intramural rectal hematoma have been published, no reports of spontaneous perforation in the ascending colon due to a hematoma have. We describe a patient with an ascending colonic perforation secondary to spontaneous intramural hemorrhage. The patient is a 35-year-old male, who presented with acute abdominal pain and no history of trauma. An abdominal computed tomography scan showed a high-density area around the ascending colon, and nonoperative management was instituted. On the eighth hospital day, the pain worsened, and abdominal computed tomography scan showed free air. An emergent right hemicolectomy was performed. Intramural hematoma and ischemia with perforation, with no obvious etiology, were found. The patient was discharged on the 14th postoperative day.

Presacral retroperitoneal hematoma after blunt trauma presents with rectal bleeding - A case report

INTRODUCTION

We present a case of a presacral hematoma, which penetrated into the rectum resulting in rectal bleeding. This is an unusual presentation of a presacral hematoma.

PRESENTATION OF THE CASE

A 76-year-old woman, using warfarin anticoagulant prophylaxis, presented with a rectal bleed two days after a fall. A sigmoidoscopy revealed that the source of bleeding was a presacral hematoma penetrating into the rectum. A Computed Tomography scan of the pelvis confirmed the presence of a hematoma measuring 10×9.4cm in the presacral space, as well as a fracture of os coccygis. She was transferred to a highly specialized facility, where she was treated conservatively with blood transfusions and repeated endoscopic toilet of the presacral cavity. One month after her initial fall, the patient had fully recovered.

DISCUSSION

Rectal bleeding usually causes suspicion of a bleeding in the gastrointestinal tract. In this report the patient's anticoagulant treatment has likely contributed to bleeding and the formation of the hematoma. To our knowledge, this is the first case report of a presacral hematoma acutely penetrating into the rectum and causing lower gastrointestinal bleeding.

CONCLUSION

Rectal bleed after trauma, in a patient receiving anticoagulant treatment, should raise suspicion of a penetrating hematoma, and such patients should be managed at highly specialized facilities.

Postoperative Sigmoid Apoplexy: A Rare Entity in Pediatric Gastroenterology

An 11-year-old boy underwent ligation of sac for left congenital hydrocele. In the immediate postoperative period, he developed bleeding per rectum and obstructive features. Intramural hematoma of sigmoid colon was detected in diagnostic laparoscopy and confirmed by laparotomy. Sigmoidectomy with colorectal anastomosis was done. Postoperative period was uneventful.

How to cite this article: Jagannathan M, Krishnamurthy G. Postoperative Sigmoid Apoplexy: A Rare Entity in Pediatric Gastroenterology. Euroasian J Hepato-Gastroenterol 2014;4(2):110-112.