Idiopathic spontaneous intramural hematoma of the colon: a case report and review of the literature

A Case of Direct-Acting Oral Anticoagulant-Induced Intramural Colon Hematoma Successfully Treated by Laparoscopic Surgery

Intramural intestinal hematoma is a rare disease, one of the triggering factors of which is the use of anticoagulants. In previous reports, most patients were on treatment with warfarin. Herein, we report a case of direct-acting oral anticoagulant (DOAC)-induced intramural hematoma of the ascending colon in a patient refractory to conservative treatment and required laparoscopic right hemicolectomy. An 80-year-old male patient with a history of atrial fibrillation and cerebral infarction, on treatment with apixaban, was brought to our hospital with the chief complaints of abdominal pain, vomiting, and melena. Imaging revealed the cause of symptoms to be intestinal obstruction caused by a mass lesion on the wall of the ascending colon. We initially opted for conservative treatment with discontinuation of apixaban and insertion of an ileus tube. Intestinal dilatation findings showed improvement; however, subsequent imaging examinations did not reveal the shrinkage of a lesion in the ascending colon. If the mass was not removed, recurrence of bowel obstruction symptoms was expected, so we decided to perform surgical intervention. A laparoscopic right hemicolectomy was performed, and an intramural hematoma of the ascending colon was diagnosed based on the excised specimen. He needed a blood transfusion for anemia but was discharged on postoperative day 14 with no other complications. DOACs are now widely used in patients with atrial fibrillation, and the risk of bleeding as a side effect is extremely low compared to conventional anticoagulants, including warfarin. However, when abdominal pain occurs, as in the present case, an intramural hematoma should be considered in the differential diagnosis. There is no established treatment plan for intestinal intramural hematoma. Although conservative treatment is effective in some cases, it is difficult to evaluate the risk of bleeding associated with DOACs using coagulation tests. Even if conservative treatment is selected, it is essential to determine surgical resection, if necessary, based on the clinical course and imaging and blood test findings.

Systemic AL amyloidosis with multiple submucosal hematomas of the colon: a case report and literature review

Amyloid light-chain (AL) amyloidosis rarely causes colorectal submucosal hematoma. A 76-year-old man presented with a complaint of bloody stool. An initial colonoscopy revealed ulcerative lesions in the descending colon, leading to a diagnosis of ischemic colitis. One month later, he presented with cardiac failure, suspected cardiac amyloidosis, and underwent a second colonoscopy. Although it revealed multiple ulcerative lesions from the ascending to transverse colon, biopsy samples did not confirm amyloid deposition. He underwent a third colonoscopy 3 weeks later due to recurrent bloody stool. It showed multiple submucosal hematomas from the ascending to descending colon concomitant with ulcerative lesions in the descending colon and multiple elevated lesions in the sigmoid colon. Biopsy samples confirmed amyloid deposition. Using a systemic search, multiple myeloma with AL amyloidosis was diagnosed. Colorectal submucosal or intramural hematomas are conditions usually encountered in trauma, antithrombotic use, or coagulation disorders. Based on our review of the literatures, we identified several differences between colorectal intramural hematoma caused by amyloidosis and those caused by other etiologies. We believe that amyloidosis should be considered when relatively small and multiple colorectal hematomas, not restricted to the sigmoid colon, and with concomitant findings of erosions and ulcers, are observed.

Colonic Intramural Hematoma in a Cat: A Case Report

Colonic intramural hematoma is a rare condition in humans and companion animals. Its clinical presentation in cats has not previously been reported. An 8-year-old male American shorthair cat presented with acute onset of constipation and anorexia for 3 days. Laboratory examination indicated mild elevation of alanine aminotransferase, globulin, and total protein levels. Complete blood count was normal. Radiographs revealed a soft tissue opacity mass located caudodorsally to the urinary bladder, causing narrowing of the descending colonic lumen. Sonography showed a heteroechogenic intraluminal mass containing liquefied content between the submucosal and muscular layers of the descending colon. On computed tomographic images, the mass contained two different attenuated contents with an interface. Colonoscopy was then performed for intestinal biopsy, and the contents observed in the intraluminal mass were drained via surgical evacuation and considered as blood clots. Supportive medical treatment, including antibiotics and fecal softener, was administered, and the clinical signs resolved uneventfully. Mild chronic proctitis without apparent malignancy was confirmed histopathologically, and no recurrence was observed after more than 14 months, and thus a colonic intramural hematoma was presumptively diagnosed. The information provided by multimodal imaging of the mass was essential for the diagnosis and determination of the treatment in this case.

Perspectives and Management Strategies for Acute Colonic Intramural Hematoma

Acute intramural hematoma of the colon is a rarely encountered clinical condition with diverse precipitating factors. Different acute and chronic complications emerge following hematoma formation, mandating high clinical suspicion for early diagnosis and optimum management. CECT represents the cornerstone for the proper demonstration of colonic hematomas and possible detection of complications as well as the underlying etiology. There are multiple strategies for management of intramural hematoma and treatment should be tailored according to the etiology and the clinical condition of the patient, reserving surgical intervention for unstable or complicated cases. Endoscopic management of colonic hematomas offers a promising minimally invasive modality with potential safety and efficacy.

Delayed presentation of intramural cecal hematoma with challenges in the treatment. A case report and review of the literature

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Intramural cecal hematoma is a rare condition with only 14 reported cases.

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It can mimic acute appendicitis.

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A history of trauma, if present, may offer a pointer to the diagnosis.

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Conservative treatment is the first choice in management. However, surgery still has a role.

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Evacuation of cecal hematoma can preserve the colon in selected patients.

Introduction

Intramural cecal hematomas are rarely encountered clinical entities with only 14 cases reported in our literature. It is usually reported after blunt external trauma, endoscopy-related trauma, coagulopathies, and occasionally spontaneous. Most cases presented acutely after primary insult; however, a delayed presentation rarely can occur.

Case presentation

Herein we describe an 8-year-old male patient who presented to the emergency department with an appendicitis-like picture six weeks after a history of falling. Intraoperatively, the patient was found to have a normal appendix. However, a large intramural cecal hematoma contains black blood with many clots was found. The patient was treated by hematoma evacuation with preservation of the cecum and colon and he was discharged with uneventful recovery. During two years follow up there was no history of complications or recurrence.

Discussion

Intramural cecal hematoma could be presented with various symptoms that range from mild abdominal pain to severe abdominal pain with vomiting, intestinal obstruction, bowel perforation, and hemoperitoneum. Diagnosis is challenging, and CT scan is the key for diagnosis. Although Conservative therapy is the first-line treatment; however, surgery still has a role in selected cases.

Conclusion

The authors report the first case of cecal hematomas with a delayed presentation. The optimal treatment should be individualized according to different etiologies, the patient's stability, and the presence of complications.

Traumatic Acute Colonic Intramural Hematoma: A Rare Entity and Successful Expectant Approach

Acute intramural hematoma in colon is a rare presentation following trauma. There are reports in literature of acute colonic hematoma following trauma, warfarin intake and in patient with coagulation disorders. In traumatic acute colonic intramural hematoma, most of the reported cases were managed surgically. Very few cases were successfully managed conservatively. We present a case of 28-year-old male who presented to the surgical emergency after two days of road traffic accident. After relevant investigations, he was found to have intramural hematoma of ascending colon, which was managed conservatively.

Idiopathic intramural hematoma of the right colon. A case report and review of the literature

INTRODUCTION

Intestinal hematoma is usually observed after an abdominal trauma or in patients treated with anticoagulant therapy. Conversely, idiopathic bowel hematoma is very rare, being colon involvement sporadic with few reports in the Literature.

PRESENTATION OF CASE

The Authors report a case of idiopathic spontaneous large bowel hematoma. A 48-year-old man was admitted for a thoraco-abdominal pain and signs of acute abdomen and fever. After ruling out heart diseases, a CT scan revealed a marked thickening of the ascending colon wall, obstructing the bowel lumen. Leukocytosis was observed. In an emergency setting, an explorative laparotomy was performed. Hemoperitoneum and a large hematoma involving the caecum and the ascending colon were detected, together with intramesenteric and retroperitoneal blood effusion. A right hemicolectomy was accomplished. Histopathology confirmed the diagnosis of large bowel hematoma. Post-operative molecular diagnostic testing for coagulative disorders failed to demonstrate any genetic variation associate with hemorrhagic predisposition. In the post-operative course, the patient experienced a left basal bronco-pneumonia with increased unilateral pleural effusion, successfully treated by a thoracic drain and antibiotic therapy.

DISCUSSION

The reported case and Literature data show that diagnosis of idiopathic colon intramural hematoma is challenging, especially in the emergency setting. Although conservative therapy is the first line treatment, surgery still has an important role when the diagnosis is uncertain, medical treatment fails or a complication, such untreatable bleeding, perforation or occlusion occur.

CONCLUSION

The Authors report a very rare case of spontaneous intramural hematoma of the right colon. Surgery still has a role in selected cases.

Colonic Perforation Secondary to Idiopathic Intramural Hemorrhage

Intramural colonic hemorrhage is rare and often secondary to trauma or anticoagulation therapy. Idiopathic intramural hemorrhages in the alimentary tract have rarely been reported. While several reports of spontaneous perforation of an intramural rectal hematoma have been published, no reports of spontaneous perforation in the ascending colon due to a hematoma have. We describe a patient with an ascending colonic perforation secondary to spontaneous intramural hemorrhage. The patient is a 35-year-old male, who presented with acute abdominal pain and no history of trauma. An abdominal computed tomography scan showed a high-density area around the ascending colon, and nonoperative management was instituted. On the eighth hospital day, the pain worsened, and abdominal computed tomography scan showed free air. An emergent right hemicolectomy was performed. Intramural hematoma and ischemia with perforation, with no obvious etiology, were found. The patient was discharged on the 14th postoperative day.

Computed Tomography and Magnetic Resonance Imaging Findings in a Case of Colonic Intramural Hematoma After Mild Blunt Abdominal Trauma

Intramural hematomas can occur along any part of the gastrointestinal tract, being more common in the duodenum, jejunum, and ileum. Intramural colonic hematomas are very rare, and their main causes include abdominal trauma, anticoagulation, and coagulopathies. We report on a 27-year-old man with right lower quadrant pain for 1 day after a mild blunt trauma sustained during a soccer match. Computed tomography and magnetic resonance imaging evaluation revealed an intramural hematoma of the right colon, subsequently confirmed and drained through laparoscopic surgery. Although computed tomography and magnetic resonance imaging findings in such a context are scarce in the radiological literature, imaging has an important role in the preoperative diagnosis and evaluation of the extent of bowel hematomas to assist in treatment planning.