Acute colonic intramural hematoma: a rare complication of colonoscopy

Abstract

Acute colonic intramural hematoma: a rare complication of colonoscopyA 74-year-old man with a medical history of chronic renal failure and congestive heart failure underwent diagnostic colonoscopy following a positive fecal occult blood test. He was given oral antiplatelet medications including aspirin (100 mg/ day) and sarpogrelate hydrochloride (100 mg/day), which were stopped 5 days before colonoscopy. During the procedure, difficulty was encountered in reaching the ileocecal valve because of a redundant tortuous sigmoid colon, and the procedure took approximately 1 hour.On withdrawal of the colonoscope, a bright-red, hyperemic, elevated mass with some oozing blood was identified in the sigmoid colon, although no abnormalities had been detected on insertion. The colonic lumen was occupied by the mass, the surface of which was smooth and covered with normal colonic mucosa (• " Fig. 1). Urgent abdominal computed tomography (CT) showed a soft tissue mass of the sigmoid colon with a density suggesting blood (• " Fig. 2). There was no evidence of free air. On the basis of these findings, a diagnosis of colonic intramural hematoma was made. As the patient's condition was stable, he was treated conservatively with observation. Three days later, follow-up colonoscopy showed that the hematoma had ruptured and disappeared, having reverted spontaneously back to flat mucosa (• " Fig. 3). The patient was discharged home 5 days later free of symptoms. Colonoscopy is a relatively safe procedure, and the most common complications such as bleeding and perforation are rare [1]. In our patient, excessive intraluminal pressure on the sigmoid colon caused by insertion of the colonoscope may have led to injury of intramural vessels.Colonic intramural hematoma is an extremely rare complication of diagnostic colonoscopy and has been described in only two cases [2,3], both of which were detected by CT within the first 12 hours after colonoscopy. To the best of our knowledge, ours is the first case diagnosed as colonic intramural hematoma during colonoscopy. Endoscopy_UCTN_Code_CPL_1AJ_2ABCompeting interests: None Cases and Techniques Library (CTL) E180Katsurahara Masaki et al. Acute colonic intramural hematoma: a rare complication of colonoscopy … Endoscopy 2014; 46: E180-E181This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Intramural Hematoma Causing Hematochezia After Colonoscopy With Polypectomy

“…In cases of intramural hematoma after diagnostic colonoscopy without polypectomy, the patients noticed hematochezia 6 and 12 hours after the procedure, and in one case, hematoma was noticed during the same colonoscopy on withdrawal. 7 Our patient presented with hematochezia 72 hours after the colonoscopy. Unlike in other described cases, abdominal pain was not present in our case.…”

“…9 A similarity between our case and those published in the literature is that more than half of the patients with intramural hematoma were taking antithrombotic agents. 2,4,6,7,9…”

Perspectives and Management Strategies for Acute Colonic Intramural Hematoma

“…Contrast-enhanced CT (CECT) along with colonoscopy is the modality of choice for diagnosis of colonic intramural hematoma. 13 It has been suggested that non-contrast CT should be performed for oral and intravenous contrast medium application, as contrast-enhanced CT alone may mask the presence of intramural hemorrhage. 6 Computed tomography diagnostic criteria of colonic hematomas include eccentric or circumferential wall thickening, intramural hyper-density, narrowing of the lumen and intestinal obstruction, as shown in Figure 1 .…”

“… 25 Although an intramural hematoma can be primarily associated with an invasive endoscopic procedure, including biopsy or therapeutic procedures, an incidence of spontaneous intramural hematomas during a diagnostic colonoscopy has been reported in a few cases. 13 …”

Immediate Endoscopic Management of an Intramural Hematoma Developed during Colonoscopy

“…An intramural hematoma of the gastrointestinal tract could be precipitated by an endoscopic examination, especially in patients being administered anticoagulation therapy or those with concomitant hematological diseases [ 1 ]. Although an intramural hematoma can be primarily associated with a biopsy or therapeutic procedure, occurrence of a spontaneous intramural hematoma during a diagnostic colonoscopy has been reported in a few cases [ 2 - 4 ]. Intramural hematomas are known to cause partial or complete bowel obstruction [ 5 ], and surgical treatment should be considered in patients with evidence of intestinal necrosis, peritonitis, or a deteriorating general condition despite conservative management [ 6 , 7 ].…”