Spontaneous rectal intramural hematoma: A rare complication of anticoagulant therapy

Bashir Attuwaybi, MD

Chief Resident Department of General Surgery

Jeffrey J. Visco, MD

Clinical Assistant Professor Department of Colorectal Surgery

Bryan N. Butler, MD

Clinical Assistant Professor Department of Colorectal Surgery

George G. Barrios, MD

Clinical Assistant Professor Department of Colorectal Surgery

Amarjit Singh, MD

Clinical Assistant Professorand Chief Department of Colorectal Surgery University at Buffalo Buffalo, NY

ABSTRACT Introduction: Intramural hematomas are a rare cause of external lower gastrointestinal bleeding, and only two other cases noting rectal involvement have been published in the literature. Several predisposing factors have been reported, including the use of anticoagulant therapy.

Results and discussion: The authors report a third case of spontaneous rectal intramural hematoma in a patient who was on anticoagulant medication. Unlike the two previously reported cases, this patient was successfully treated using conservative measures.

Conclusion: The authors conclude that conservative management of spontaneous intramural rectal hematomas is the best option because it is safer than surgery, especially in high-risk patients on anticoagulant therapies.

External lower gastrointestinal bleeding is commonly caused by cancer, diverticulitis, hemorrhoids, or colitis, or occurs as a result of anticoagulation theapy.¹ Intramural hematomas of the intestine are a rare cause of lower gastrointestinal bleeding and usually result secondary to penetrating or blunt abdominal trauma. They have been found in every portion of the alimentary tract, from the esophagus to the sigmoid colon, but the duodenum, jejunum, and ileum are the most common sites.

We report a rare case of a spontaneous intramural hematoma of the rectum and colon. In our review of the literature from 1965 to the present, we found only two cases of spontaneous rectal intramural hematomas. One case was managed using loop sigmoid colostomy and the other with incision and drainage.¹,² We chose a conservative approach, closely monitoring the patient with radiological intervention, and her spontaneous rectal intramural hematoma resolved.

CASE REPORT

A 64-year-old, obese woman presented to the emergency department after the acute onset of rectal and abdominal pain and slight rectal bleeding, tenesmus, and nausea, which had started approximately 36 hours earlier. Despite tenesmus and the urge to stimulate herself digitally, she was unable to produce stool. The patient reported no recent vomiting, diarrhea, weight loss, or history of rectal instrumentation or trauma. She often experienced chronic constipation, and her last bowel movement had occurred approximately 24 hours before the onset of her current symptoms, which was a normal frequency for her.

The patient's surgical history included lysis of adhesions with small bowel resection to treat bowel obstruction 6 years earlier and gastric bypass to treat her morbid obesity 4 years earlier. Her medical history was significant for high blood pressure, atrial fibrillation, depression, and hypothyroidism. She was taking several medications to treat these conditions, including warfarin, diltiazem, levothyroxine, and venlafaxine. The patient appeared alert, somewhat pale, and in moderate distress. Her abdomen had vertical midline scars from her previous surgeries. There were no gross peritoneal signs, and decreased bowel sounds were noted on auscultation. A rectal examination revealed normal sphincter tone on voluntary squeezing and hemorrhoids. A circular pattern of bruising surrounded the entire anal area, and bright red blood was noted at the orifice (Figure 1). No masses, fistulas, abscesses, or fissures were found.

A laboratory examination was significant for a hemoglobin of 6.7 g/dL (normal, 12.0-15.0 g/dL), a white blood cell count of 11.9 x10⁹/L (normal, 4.5-11.0 x10⁹/L), and a platelet of count of 142 x10⁹/L (normal, 150-450 x10⁹/L). The prothrombin time and partial thromboplastin time were normal, at 10.1 and 25.1 seconds respectively, but the patient's international normalized ratio (INR) was elevated at 2.64 (normal, 0.8-1.2).

Practice

Points

• Small bowel hematomas can usually be treated conservatively.
• Intraventional radiology can be useful in a conservative approach.

A computed tomography (CT) scan showed significant narrowing of the bowel lumen, as well as blood tracking the bowel wall from the rectum to the transverse colon, with no extravasation into the peritoneal cavity; this was reported as both active and clotted bleeding (Figure 2). The aorta appeared normal throughout its course.

The patient was admitted to the intensive care unit (ICU). She was allowed nothing by mouth and was rehydrated with intravenous fluids. Her INR was corrected with 2 units of fresh frozen plasma (FFP) and 4 units of blood. Colonoscopy the next day showed viable and intact colonic mucosa. Despite correcting her coagulopathy, she was unable to maintain a reasonable hematocrit level. Over the next few days, the patient received an additional 7 units of blood and 4 units of FFP.

On hospital day 4, an interventional radiologist was consulted and performed an inferior mesenteric artery angiogram, which showed bleeding from a superior rectal artery branch (Figure 3). The patient was treated with a selective inferior mesenteric artery vasopressin infusion and the bleeding stopped, which was confirmed the following day by angiography. The femoral sheath was removed, and the patient remained hemodynamically stable. She was transferred from the ICU to the surgical floor a few days later and continued to improve. She was discharged to home on hospital day 14 tolerating a regular diet and producing normal bowel movements. A CT scan performed before discharge showed that the patient's hematoma had resolved and her rectal caliber was nearly normal.

DISCUSSION

Spontaneous rectal hematomas are extremely rare, and from 1965 to the present, only two other cases have been reported.^1,2 Gastrointestinal mural hematomas can occur anywhere within the gastrointestinal tract, but they are most commonly found in the jejunum. They result from trauma, anticoagulation therapies, Henoch-Sch?nlein purpura, and blood dyscrasia. More than 96% of anticoagulation-induced gastrointestinal hematomas are attributed to warfarin, with heparin responsible for only 2% of cases.²

Literature review

Abbas and colleagues noted that small bowel hematomas can extend into the colon, which they observed in 2 of 13 patients.³ Isolated cases of intramural colonic hematomas without small bowel involvement are rare, and the study identified no cases of spontaneous hematomas limited to the colon. Hughes and associates reviewed 277 cases of gastrointestinal intramural hematomas reported in the literature; 149 (53%) patients were treated for duodenal hematomas, 111 (40%) for jejunal and ileal hematomas, and 12 (4%) for colonic intramural hematomas; 2 cases were esophageal hematomas, and the remaining 3 cases involved more than one area of the gastrointestinal tract and are not included in the 277 total.⁴ Of the 277 cases, 109 (40%) were attributed to trauma and 123 (45%) were attributed to anticoagulation therapies or a bleeding disorder; the remaining 42 incidents (15%) resulted from procedures, had pancreatic involvement, or were of unknown etiology. None of the patients in the 277 reported cases had an intramural hematoma of the rectum.

Symptoms and diagnosis

The clinical presentation of a rectal hematoma is similar to that of intestinal obstruction. A hematoma as small as 30 cc can cause symptomatic small bowel obstruction, but a greater amount of blood is needed to produce colonic obstruction, possibly due to the colon's larger lumen. Patients usually experience abdominal pain, nausea, or vomiting but no signs unique to an intramural hematoma. Our patient presented with an external hematoma around the anus, which sometimes occurs after rectal trauma. Obtaining a detailed medical history is important. Patients who are undergoing anticoagulation therapy have a significant risk of bleeding, whether external or internal.

Our case and the two previously reported cases of rectal hematoma were diagnosed using CT scanning.^1,2 CT scanning with angiography is the preferred imaging modality for diagnosing the hematoma and localizing the source of bleeding.

Practice

Point

Surgical exploration should be reserved for those patients who do not respond to nonsurgical treatment or are hemodynamically unstable.

Treatment

Treatment depends on the patient's symptoms and clinical presentation. Small bowel hematomas are usually treated conservatively unless the hematoma shows no improvement after being given a chance to resolve, in which case surgery may be necessary.

In a second article that reviewed the same 13 hematoma patients, Abbas and colleagues found single hematomas in 11 patients and multiple hematomas in 2 patients.⁵ Two patients underwent exploratory surgery, but no bowel resection was performed. Because our patient was high-risk and required anticoagulation medication, we wanted to avoid surgery and its potential complications and elected to take a conservative approach. First, we corrected the patient's coagulation abnormalities. We then used the hospital's interventional radiology facilities to man-age our patient's condition, which resolved without an operation. In the two rectal hematoma cases reported previously, one patient underwent a sigmoid colostomy and the other received incision and drainage.

CONCLUSION

Intramural hematomas are rare, and spontaneous rectal hematomas are even more uncommon, with this being only the third case reported in the literature. Obtaining a detailed medical and surgical history, conducting a thorough physical examination, and using the appropriate imaging modality can ensure prompt diagnosis of an intramural hematoma. Patients on anticoagulation medication have an increased risk of bleeding, and surgical exploration should be reserved for those patients who do not respond to nonsurgical treatment or are hemodynamically unstable. Interventional radiology can facilitate a conservative approach in patients with intramural hematomas.

Disclosure

The authors have no relationship with any commercial entity that might represent a conflict of interest with the content of this article and attest that the data meet the requirements for informed consent and for the Institutional Review Boards.

REFERENCES

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4. Hughes CE 3rd, Conn J Jr, Sherman JO. Intramural hematoma of the gastrointestinal tract. Am J Surg. 1977;133(3):276-279.
5. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel hematoma: imaging findings and outcome. AJR Am J Roentgenol. 2002;179(6):1389-1394.