An Elderly Patient on Warfarin With Rectal Bleeding

Abstract

Question: An 83-year-old woman was admitted to the hospital with rectal bleeding. She complained about pain in her lower back because of a heavy fall at home 2 weeks before. Owing to atrial fibrillation and low cardiac output, she had been under constant treatment with phenprocoumon. On rectal examination, a soft mass was felt dorsal on supine position. Laboratory studies revealed abnormal coagulation tests with a prolonged prothrombin time (international normalized ratio, 2.5) and a slightly prolonged partial thromboplastin time of 38 seconds (normal, 24–36). The platelet count was within the normal range, and her serum creatinine was elevated (4 mg/dL). Because of severe anemia (hemoglobin, 7.5 g/dL), she received a pack of red blood cells. Ileocolonoscopy revealed massive diverticulosis of the entire colon and a 3-mm opening to the dorsal rectal wall with discharge of blood (Figure A). Computed tomography without contrast enhancement because of impaired renal function was performed, revealing a 7 × 7-cm round, liquid mass (Figure B) that could also be demonstrated by rectal endosonography (Figure C). Correlating her clinical and imaging findings, what is your diagnosis? Look on page 270 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Colonoscopy suggested a fistula of the rectum, and computed tomography showed a large presacral, retro-rectal mass consistent with a hematoma. Next, contrast-enhanced fluoroscopy was performed using a catheter inserted into the presumed rectal fistula by flexible rectoscopy, demonstrating connection of the hematoma with the rectum. Phenprocoumon was stopped, and vitamin K was given leading to normalization of the prothrombin time. The patient was started on ceftriaxone and metronidazole and underwent surgery 2 days later. Transrectal evacuation of the hematoma and irrigation with saline were performed, and the perforation site was closed by transanal suture. A corrugated drain was inserted into the rectal space and removed 5 days later. The further course was uneventful, and the patient was discharged. Anticoagulation with phenprocoumon was resumed. Systemic anticoagulation is a frequent cause of gastrointestinal bleeding, especially if predisposing conditions are present.1Ahsberg K. Höglund P. Kim W.H. et al.Impact of aspirin, NSAIDs, warfarin, corticosteroids and SSRIs on the site and outcome of non-variceal upper and lower gastrointestinal bleeding.Scand J Gastroenterol. 2010; 45: 1404-1415Crossref PubMed Scopus (56) Google Scholar However, most studies have focused on the upper gastrointestinal tract. According to the available data, up to 40% of patients with lower gastrointestinal bleeding were under anticoagulant and/or antiplatelet therapy. The most common cause of colorectal bleeding in these patients is diverticulosis, accounting for >50% of cases. Other causes of lower gastrointestinal bleeding in patients under long-term anticoagulation include in addition, polyps, arteriovenous malformations, hemorrhoids, colorectal cancer, ulceration, and colitis/proctitis. Perirectal hematoma after rectal stapled mucosectomy for hemorrhoids and rectus sheath hematoma associated with abdominal trauma and/or anticoagulation therapy has been described previously.2Hidalgo G.L.A. Heredia B.A. Fantova M.J. et al.Perirectal haematoma and hypovolaemic shock after rectal stapled mucosectomy for haemorrhoids.Int J Colorectal Dis. 2005; 20: 471-472Crossref PubMed Scopus (18) Google Scholar, 3Klingler P.J. Wetscher G. Glaser K. et al.The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders.Sur Endosc. 1999; 13: 1129-1134Crossref PubMed Scopus (83) Google Scholar To our knowledge, however, this is the first report of a perirectal hematoma leading to severe lower gastrointestinal bleeding.