PICTURES IN DIGESTIVE PATHOLOGY

 

Spontaneous intramural hematoma of the colon

 

 

Samuel Raimundo Fernandes, Ana Rita Gonçalves and Luís Araújo Correia

Department of Gastroenterology and Hepatology. Hospital de Santa Maria. Centro Hospitalar Lisboa Norte. Lisbon, Portugal

 

 

Case Report

A 73-year-old man was admitted to our clinic with sudden left quadrant abdominal pain and hematochezia. There was no history of trauma. He denied other symptoms or taking off-the-counter medication. His medical history was relevant for ischemic and aortic-mitral valve disease with prosthetic valves for which he was medicated with aspirin and warfarin. On physical examination the patient presented normal vital signs with tenderness on palpation of the left side of the abdomen. Laboratory tests revealed moderate anemia (10.8 g/dl) and thrombocytopenia (135,000 x 10⁹ U/L) with therapeutic international normalized ratio (2.53). Colonoscopy revealed an extensive area of erythematous and bluish mucosa with an apparent torsion of the proximal descending colon around a voluminous hematoma measuring 6.5 x 3 cm (Figs. 1 A-C). Urgent abdominal CT confirmed the presence of a large intramural hematoma of the descending colon (Figs. 2 A and B). A conservative approach was adopted with temporary suspension of anticoagulation. Given the high thrombotic risk, abdominal ultrasound was performed after 72 hours showing considerable reduction in the size of the hematoma. Anti-coagulation was then resumed without complications. One month later, colonoscopy was repeated, showing complete healing of the mucosa.

 

 

 

Discussion

The increasing use of anti-aggregating and anti-coagulant therapy, especially in elderly patients, explains the increasing incidence of bleeding events seen in this population. However, gastrointestinal hematomas are estimated to occur in only 1 for every 250,000 anti-coagulated patients (1). Diagnosis is based on characteristic radiologic findings. While most parietal hematomas can be approached conservatively, surgery is indicated in the presence of complications or persistence of the hematoma (1,2).

 

References

1. Abdel Samie A, Theilmann L. Risk factors and management of anticoagulant-induced intramural hematoma of the gastrointestinal tract. Eur J Trauma Emerg Surg 2013;39:191-4. DOI: 10.1007/s00068-013-0250-1.         [ Links ]

2. Altintoprak F, Dikicier E, Akyüz M, et al. A retrospective review of patients with non-traumatic spontaneous intramural hematoma. Turk J Gastroenterol 2013;24:392-9.         [ Links ]