Rectal colonic mural hematoma following enema for constipation while on therapeutic anticoagulation

Abstract

Causes of colonic and recto-sigmoid hematomas are multifactorial. Patients can present with a combination of dropping hemoglobin, bowel obstruction and perforation. Computed tomography imaging can provide clues to a diagnosis of intramural hematoma. We present a case of rectal hematoma and a review of current management literature. A 72-year-old male on therapeutic anticoagulation for a pulmonary embolism, was administered an enema resulting in severe abdominal pain unresponsive to blood transfusion. A sigmoid colectomy with end colostomy was performed. Although rare, colonic and recto-sigmoid hematomas should be considered as a possible diagnosis for adults with abdominal pain on anticoagulant therapy.

Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines

“…The use of enemas involves risks of perforation of the intestinal wall (which should be anticipated and suspected if abdominal pain occurs), rectal mucosal damage and bacteraemia. Patients on therapeutic or prophylactic anticoagulation or who are affected by coagulation and platelet disorders are at risk of bleeding complications or intramural haematomas [73,74].…”

A Rare Case of Traumatic Colonic Intramural Hematoma in Saudi Arabia

“…Colonic intramural hematomas can be approached conservatively if the patient is stable clinically and hemodynamically without any sign of peritonitis, while surgical management is indicated in unstable cases or with the presence of complications such as an acute drop of hemoglobin or an expanding hematoma despite conservative management [8][9][10].…”

Perspectives and Management Strategies for Acute Colonic Intramural Hematoma

“… 16 Rigid proctoscopy is considered a precious adjunctive diagnostic modality which demonstrates colonic intramural hematomas as round-shaped, dark-reddish submucosal masses or lesions often causing luminal obstruction of the lumen. 17 On the other hand, colonoscopy could reveal a localized, submucosal mass with variable mucosal manifestations, as shown in Figure 2 , which demonstrates a case of colonoscopy-induced intramural hematomas in a 16-year-old patient most likely secondary to looping of colonoscope and loop reduction maneuvers. 2 , 18 Different signs can be illustrated by barium studies denoting the presence of intramural hematoma, including coiled spring or picket fence sign or stacked coin sign.…”

“…It should be noted that identification of patients with self-limiting intramural hematoma from those with more severe pathology represents a serious clinical challenge as routine clinical examination is insufficient to identify serious life-threatening cases and even a simple hematoma may also present with hyperthermia, leukocytosis and peritoneal signs. 17 …”