LETTERS TO THE EDITOR

Spontaneous intramural hematoma of the cecum

Hematoma intramural espontáneo de ciego

Key words: Intramural hematoma of cecum. Hemoperitoneum. Acute abdomen.

Palabras clave: Hematoma intramural de ciego. Hemoperitoneo. Abdomen agudo.

Dear Editor,

Spontaneous intramural hematoma of cecum is a rare entity which diagnosis is established after radiological imaging or exploratory surgery. Emergency right hemicolectomy seems to be the best approach because of the high risk of hemoperitoneum due to rupture, whereas a conservative management is indicated for hematomas at other gastrointestinal sites. We report a case of spontaneous intramural hematoma of the cecum.

Case report

A 54-year-old female patient presented with a spontaneous right lower quadrant pain and hyporexia of five day's duration without diarrhea or dysuria. Her past medical history included a diagnosis of arterial hypertension and non insulin-dependent diabetes mellitus treated with enalapril, metformin and acetylsalicylic acid. On physical examination, she had abdominal distension and right lower quadrant pain without guarding or rebound tenderness. Laboratory tests revealed only high levels of fibrinogen (811 mg/dl) and C reactive protein (12 mg/dl). Abdominal computed tomography (CT) scan showed a 4 x 3 x 5 mass close to the cecum with an 8 mm-diameter appendix. Differential diagnosis included acute appendicitis and complicated cecum tumor. An exploratory laparoscopy was performed which revealed a cecum hematoma and hemoperitoneum, and she underwent a right hemicolectomy with an uneventful postoperative recovery. Histopathology revealed an intramural hematoma of the cecum with focal abscessification but no malignant signs (Fig. 1).

Discussion

Intramural hematoma of the bowel is a rare entity which can be spontaneous (associated with blood dyscrasias, anticoagulant or antiagregant therapy, mainly warfarin) or secondary to blunt abdominal trauma by tearing of the terminal arterial vessels as they leave the mesentery to penetrate the intestinal wall. The first report was published in 1838 by McLauchlan, who described a bowel obstruction due to traumatic duodenal hematoma. In 1904, Sutherland published the first case of spontaneous intramural hematoma in a child with Schönlein-Henoch purpura. Literature data consist of case reports and clinical series with few patients; in fact, the two major series have 13 and 7 patients, respectively. However, the incidence is expected to increase because of several factors, including hematologic malignancies, chemotherapy, long-term antiagregant or anticoagulant therapy in several diseases such as atrial fibrillation, prosthetic valves, etc.).

Intramural hematoma is usually single, located in the submucosal layer, and can occur in any segment of the gastrointestinal tract, but most commonly involves the small-bowel, typically the jejunum (the duodenum is the most commonly affected in traumatic small-bowel hematomas). Large-bowel hematomas with or without small-bowel involvement are rare, and the reason is uncertain. We have found less than 10 reported cases of isolated cecum involvement, including our own. The development of spontaneous hematoma has been reported as early as 10 days after initiation of anticoagulant therapy (1-3).

Clinical presentation includes abdominal pain, gastrointestinal bleeding, bowel obstruction, or acute abdomen due to hemoperitoneum. Often, the diagnosis is not suspected and is only established after radiological imaging [abdominal ultrasound or CT scan with oral and intravenous contrast media, showing circumferential wall thickening with or without free intraperitoneal fluid (hemoperitoneum)], or after exploratory surgery. The length of involved bowel appears longer in spontaneous hematomas due to coagulation disorders (1-5).

Conservative management seems to be the best approach, except in cases of uncertain diagnosis, ischemia, perforation, active intraluminal hemorrhage or lack of recovery, because hematomas cause a transient stricture which will heal without sequelae in most cases. However, cecum hematoma behaves differently from other gastrointestinal sites in that its location between the free ileum and retroperitoneal right colon prevents it from enlarging, and produces its rupture into the peritoneal cavity, something that has occurred in all the reported cases. Therefore, intramural hematoma of the cecum must be closely monitored because its rupture appears to be the rule, and an emergency right hemicolectomy seems to be the best approach (1-3).

A. García Marín, J. Martín Gil, T. Sánchez Rodríguez, B. Díaz-Zorita and F. Turégano Fuentes

Department of Emergency Surgery. University Hospital Gregorio Marañón. Madrid, Spain

References

1. Abbas MA, Collins JM, Olden KW, Kelly SA. Spontaneous intramural small-bowel hematoma: clinical presentation and long-term outcome. Arch Surg 2002; 137: 306-10.        [ Links ]

2. Polat C, Dervisoglu A, Guven H, et al. Anticoagulant induced intramural intestinal hematoma. Am J Emerg Med 2003; 21: 208-11.        [ Links ]

3. Calabuig R, Ortiz C, Sueiras A, Vallet J, Pi F. Intramural hematoma of the cecum: report of two cases. Dis Colon Rectum 2002; 45: 564-6.        [ Links ]

4. Lee SH, Lee JH, Park DH, et al. Intramural colonic hematoma: complication of anticoagulation with heparin. Gastrointest Endosc 2005; 62: 783-4.        [ Links ]

5. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small bowel hematoma: imaging findings and outcome. Am J Radiol 2002; 179: 1389-94.        [ Links ]