Active Cecal Hematoma Formation during Colonoscopy

Abstract

Purpose: Cecal hematoma is rare and is typically due to blunt trauma. We present a case of spontaneous cecal hematoma formation induced during routine colonoscopy. Methods: An 86 year old male presented with five episodes of hematochezia. He denied prior episodes, abdominal pain, vomiting, chest pain, or syncope, though intermittent dizziness for one week was reported. He had been taking a baby Aspirin at home. His medical history included hypertension, chronic renal disease, gout, and myocardial infarction with angioplasty over twenty years ago. Results: On examination,he was orthostatic. Nasogastric lavage revealed nonbloody bilious fluid. The abdomen was nontender. Dark stool with blood was noted on rectal exam. Vital signs were within normal limits. Laboratory evaluation revealed a drop in hemoglobin from 12.8 to 10.4 g/dL, platelet count of 176 K/uL,and normal coagulation profile. The patient was placed on an IV proton pump inhibitor and transfused 3 units of packed red blood cells. EGD was unremarkable. On colonoscopy, scattered diverticuli and internal hemorrhoids were seen, but no blood during insertion. During an attempted ileal intubation, as water jet irrigation was employed for visualization, mucosal fibriability was appreciated with transient oozing from mucosa overlying the IC valve. A 3 cm submucosal hematoma spontaneously formed at base of cecum. After 10 minutes, the hematoma stabilized in size. Three days later, colonoscopy was repeated and again identified the cecal hematoma and diverticuli. SPEP and UPEP were negative. Conclusion: Risk factors for a cecal hematoma are adhesions, technical difficulty of the procedure, overdistention due to air insufflation, anticoagulation therapy, or coagulopathy such as amyloidosis. Being that the cecum has the largest diameter and thinnest wall, wall stress is increased, lending to pressure-related injury. Furthermore, because the cecum lies between free ileum and retroperitoneal right colon, a cecal hematoma can easily rupture into the peritoneal cavity. In the event of hemodynamic instability, active bleeding, or rupture of the hematoma, emergent surgical therapy (e.g., hemicolectomy, hematoma evacuation) is necessary. Our patient had no underlying coagulopathy. Hematoma was induced during routine irrigation. Aside from close observation, no aggressive intervention was needed.Figure: Spontaneous submucosal cecal hematoma.