Spontaneous presacral haematoma mimicking rectal malignancy - an unusual consequence of anticoagulation

Abstract

An 81-year-old man on warfarin was admitted to hospital after 3 days of constipation, straining and mild rectal bleeding. A large, boggy mass was felt posteriorly on direct rectal examination. Investigations revealed a normocytic anaemia and a supratherapeutic international normalised ratio (INR). Fearing a late presentation of malignancy, an urgent CT of abdomen and pelvis was arranged which showed a homogeneous mass arising between the sacrum and the rectum. Given the anaemia in the presence of anticoagulation, and subsequent widespread perineal and scrotal ecchymosis, the patient was diagnosed with atraumatic presacral haematoma. Following resuscitation, the patient was managed non-operatively and was discharged several days later following stabilisation of the haemoglobin and INR. At 3 months, he had complete clinical and radiological resolution of this haematoma.

Presacral retroperitoneal hematoma after blunt trauma presents with rectal bleeding — A case report

“…This case however, is different, since the source of the bleed was not localized in the actual gastrointestinal tract, but penetrated from the presacral space into the rectum, and thereby presented with rectal bleeding. Three cases of presacral hematomas have previously been described [9] , [10] , [11] . In these cases, the patients presented with diarrhea, abdominal pain or pain in the rectum while sitting [9] , [10] , or mimicking rectal malignancy by presenting as a large, boggy mass, felt during rectal examination [11] .…”

“…Three cases of presacral hematomas have previously been described [9] , [10] , [11] . In these cases, the patients presented with diarrhea, abdominal pain or pain in the rectum while sitting [9] , [10] , or mimicking rectal malignancy by presenting as a large, boggy mass, felt during rectal examination [11] . Rectal bleeding was not the main symptom, and only in one of these cases was a minor rectal bleeding reported.…”

“…In at least three cases in literature, a perforated intramural hematoma has presented with rectal bleeding [6] , [7] , [8] , but to our knowledge, this is the first time a presacral hematoma, secondary to blunt trauma, has penetrated directly into the rectum and presented with rectal bleeding. Presacral hematomas have been described in connection with either trauma [9] , [10] or anticoagulant treatment [11] , but patients, described in these case reports, have presented with other symptoms than rectal bleeding. One case has been reported, where a presacral hematoma communicated with the rectum through a fistula and presented with a rectal bleed [12] .…”