Intramural Colonic Hematoma

Abstract

Introduction: Intramural colonic hematomas are extremely rare, accounting for 5% of all intramural hematomas, and are usually found after acute trauma or in the setting of bleeding diatheses. Spontaneous intestinal intramural hematomas in patients on oral anticoagulant therapy occur in 1/2500 patients. We report here a rare and dramatic case of an intramural colonic hematoma in an 89-year-old male taking anti-platelet agents with a colonic hematoma. Case Report: An 89-year-old male with history notable for ischemic cardiomyopathy (on aspirin and Clopidogrel) and chronic constipation presented to the hospital with urosepsis. His hospital course was complicated by 3 episodes of bright red blood per rectum and hypotension. He had no history of past gastrointestinal hemorrhage or abdominal trauma. He had a remote history of subtotal colectomy for colonic volvulus. He had never undergone any prior endoscopic evaluation. His physical exam was notable for moderate cachexia and a normal abdomen. There was bright red blood within the vault and external hemorrhoids, but no rectal mass. His hematocrit was 39.0% and INR was 1.1. Colonoscopy revealed a 19 cm intra-colonic hematoma extending to the recto-sigmoid junction (Fig. 1) with near complete obstruction. Computed tomography revealed the hematoma to be 8.0 cm x 8.8 cm in crosssection (Fig. 2). There was no intra-abdominal blood. The patient was successfully managed conservatively with a titrated bowel regimen and cessation of Clopidogrel. There was no evidence of colonic ischemia or recurrent bleeding.Figure 1Figure 2Discussion: We present here a rare case of an intramural colonic hematoma in the setting of anti-platelet agents. Although there was no obvious abdominal trauma, it is possible that increased intra-abdominal pressure due to constipation played an etiologic role. Intramural colonic hematomas should be considered in patients presenting with acute hypotension in setting of a bleeding diathesis, abdominal pain, and an acute drop in hematocrit, particularly when no gross GI bleeding is present. Our patient is unusual because he had no abdominal pain and exhibited rectal bleeding. The latter was a result of the hematoma tearing into the colonic lumen. Rare potential complications include obstruction and ischemia. Intracolonic hematomas are most often managed conservatively but may require surgical management in the setting of ischemia.