Colonic Intramural Hematoma: A Rare Cause of Lower Gastrointestinal Bleeding

Abstract

Intestinal intramural hematomas are rare. Their endoscopic appearance and treatment are not well understood. Here we report a case of acute severe lower gastrointestinal bleed from an intramural colonic hematoma in an adult patient with acquired hemophilia. A 64-year-old female with a history of hypertension, diabetes, gout and hemorrhoids presented with acute onset of severe right lower extremity pain, as well as frequent rectal bleeding. Physical exam was notable for large superficial hematoma in the right calf and labs were notable for partial thromboplastin time (PTT) 90 (normal 24-37). Hematology workup revealed low factor VIII activity with factor-specific inhibitor, consistent with acquired hemophilia, for which she was started on cyclophosphamide and prednisone. One week into her hospitalization, she had a large episode of hematochezia with associated syncope, hemoglobin (Hb) decrease from 10 to 7.5 and lactate of 5. Her Hb, PTT and factor VIII levels improved with 2 units of packed red blood cells and recombinant factor VII. Her high-volume hematochezia persisted along with ongoing coagulopathy with transfusion requirements. The risks and benefits of proceeding with endoscopic evaluation were discussed and ultimately pursued. Colonoscopy revealed a large subepithelial hematoma near the hepatic flexure that involved two-thirds of the circumference of the wall and extended proximally at least 10 cm (Image), without evidence of active bleeding. Cross-sectional imaging ruled out transmural involvement or bowel necrosis. She was started on aminocaproic acid and rituximab, but remained in the hospital for over one month receiving recombinant factor VII for ongoing intermittent bleeding. Intestinal intramural hematomas are rare but account for approximately 5% of GI bleeds in patients with hemophilia. They can also be seen in patients on anticoagulation, with vasculitis, or following blunt trauma, and are thought to be due to rupture of a terminal artery arising from the mesentery which dissects the muscularis mucosa. In addition to GI bleed, intramural hematomas can present with mass-like or obstructive symptoms. It is important to keep intestinal intramural hematomas on the differential diagnosis in patients with the risk factors outlined above, and it is essential to be able to recognize them endoscopically and on cross-sectional imaging.2009 Figure 1 No Caption available.