Clin J Gastroenterol (2009) 2:161–165 DOI 10.1007/s12328-008-0061-9

CASE REPORT

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

Received: 10 August 2008 / Accepted: 8 December 2008 / Published online: 16 January 2009 Ó Springer 2009

Abstract An 82-year-old man visited our hospital for abdominal discomfort and constipation lasting 3 days. He did not have a history of trauma or bleeding tendency. His laboratory studies showed slight anemia and inflammatory reactions, but other data including coagulation profiles were all normal. Computed tomography (CT) demonstrated a 6-cm high-density mass in the left upper quadrant and slight ascites. Contrast-enhanced CT revealed that the lesion was not enhanced. Colonoscopy could not detect the lesion. Laparotomy was performed because malignancy could not be ruled out. The mass was located in the transverse colon, and histologic examination showed intramural hematoma. Neither arteriovenous malformation nor a foreign body such as a fish bone was identified, indicating that the mass was considered to be idiopathic intramural colonic hematoma. We present this rare case and also a review of the literature. Keywords Intramural hematoma  Idiopathic  Colon  CT

Introduction Intramural hematomas of the colon are rare. They are mostly associated with trauma or bleeding tendency, and cases without any possible causative factors are extremely rare [1, 2]. This paper presents a case of idiopathic intramural colonic hematoma and a review of the literature.

T. Nozu (&) Department of Internal Medicine, Shari General Hospital, 41 Aoba-Cho, Shari, Hokkaido 099-4117, Japan e-mail: [email protected]

Case report An 82-year-old male visited our hospital because of abdominal discomfort and constipation lasting for 3 days. The patient had neither a history of trauma nor bleeding tendency. He had hypertension and had been treated with a calcium blocker, but did not take any anticoagulant medications. His blood pressure was 130/90 mmHg and pulse rate 80 beats/min. Abdomen was soft, and there was no tenderness. A complete blood cell count showed leukocyte count of 4,900/lL, slight anemia with hemoglobin 10.5 g/ dL, and platelet count 16.4 9 104/lL. Serum biochemistry studies revealed a slight inflammatory reaction with C reactive protein 0.89 mg/dL. Coagulation tests showed that activated partial thromboplastin time was 30.7 s, prothrombin time international normalized ratio was 0.89, fibrinogen 465 mg/dL, and coagulation time 11 min, which were all normal. Tumor markers such as CEA, CA19-9, and CA125 were all negative. Computed tomography (CT) revealed a 6-cm high-density mass in the left upper quadrant and slight ascites (Fig. 1a, b), and the lesion was not enhanced by contrast medium (Fig. 1c). Colonoscopy did not detect any abnormal findings. His symptoms completely disappeared after admission, and his anemia did not worsen. Nevertheless, a laparoscopic operation was performed in order to explore the unknown intra-abdominal tumor because malignancy could not be ruled out. On opening the abdominal cavity, a small amount of hemorrhagic ascites was encountered, and the mass was found at the transverse colon near the splenic flexure, which adhered to the descending colon. Partial transverse colectomy was performed, and the mass was excised. The color of the mass had partly changed to dark red, and a tiny tear with bleeding was also observed at serosal side (Fig. 2a). The

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Fig. 1 Plain CT disclosed a high-density mass (arrows) in the left upper quadrant and intraperitoneal liquid (a axial image, b coronal image). The mass was not enhanced by contrast medium (c)

lesion was soft and covered by normal colonic mucosa (Fig. 2b), and a hematoma was visible by cutting the mucosa (Fig. 2c). Histologic examination showed that the hematoma was mainly located in the muscularis without neoplastic changes (Fig. 3). A foreign body such as a fish bone was not detected. Neither arteriovenous malformation nor hemangioma was identified, indicating that the mass was considered to be idiopathic intramural hematoma of the colon. Postoperative course was good, and the patient recovered uneventfully.

Discussion Intramural hematoma is a rare condition and has been described in almost every area of the gastrointestinal tract [1]. The most common site is the duodenum; colonic hematoma accounts for only 4% of cases [1]. There have been 29 previously reported cases of colonic intramural hematoma since 1950. Table 1 summarizes the clinical characteristics of these cases including the present one. The majority of the cases were associated with trauma. The next most common cause is bleeding tendency because of hemophilia [3] or other coagulopathy [4] or warfarin therapy [5]. These findings may explain why the patients are predominantly male. Idiopathic cases are very rare and only two previous cases have been reported so far [2, 6].

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The chief complaints are symptoms associated with colonic obstruction such as abdominal pain, vomiting, and constipation. Moreover, in cases associated with bleeding tendency, melena may also be present [7, 8]. The hematoma can develop in any area of the colon; frequent sites are the sigmoid and ascending colon. Diagnosis was performed by laparotomy in early cases [6, 9, 10], and some cases underwent barium enema, which demonstrated submucosal filling defect or obstruction of the colon [4, 6, 9–15]. CT is a useful tool for diagnosis, and in trauma cases, it can also detect other intra-abdominal injuries. Recent reports detected the hematoma as a mass with various CT values [2, 14, 16–19]. This variation in CT findings may be explained by the difference in timing of when the CT was performed. The density of hematoma changes over time, reflecting clot formation, retraction, and lysis [20]. On the other hand, seeping of the contrast material into the hematoma indicates active bleeding on contrast-enhanced CT, which is helpful for judging the need for emergency surgery. Magnetic resonance imaging (MRI) was performed in only one case, and it was reported to be helpful for the diagnosis [2]. However, further studies with many cases are needed to evaluate the usefulness of MRI precisely. A colonoscopy was performed in several cases and detected a dark-colored submucosal tumor [2, 21, 22]. However, the lesion was not detected endoscopically in the

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Fig. 2 The resected specimen showed the size of the mass was approximately 60 mm in diameter, and a tiny tear (arrow) was present on the serosal side (a). The mass was covered with normal colonic mucosa (b), and hematoma was visible by cutting the mucosa (c)

Fig. 3 Histologic examination showed that the hematoma was mainly located in the muscularis (H&E 94). No abnormal findings possibly inducing intramural bleeding were identified

present case. One of the possible reasons for this discrepancy is a technical issue of endoscopy, i.e., an endoscopist might miss the lesion because it was located at the strong flexional part of the colon. On the other hand, hematoma is often found between the muscularis and the submucosa, because vessels are rich in these layers [23]. A lesion located in the submucosa was reported to be easily observed by endoscopy [2], but could be difficult to detect it was located in the deep layer of the colonic wall, such as the muscularis, as in this case.

The prognosis is good; only one case, complicated by amyloidosis, died, due not to hematoma but to renal failure and massive gastrointestinal bleeding [13]. The majority of the cases underwent surgical treatment. The main reasons for surgery in the recent cases were uncontrollable bleeding and colonic obstruction [3, 8, 24]. Hematoma itself induces obstruction, and in some cases, develops into the lead point of intussusception [8]. On the other hand, onethird of the patients were followed up with conservative therapy without operation. If an accurate diagnosis is obtained, cases without life-threatening complications may not need surgery. With recent advancements in imaging studies, precise diagnosis has been made in several cases without or before operation [2, 14]. However, all idiopathic cases including the present one underwent surgery in order to obtain definitive diagnosis and rule out malignancy [2, 6]. In the present case, intramural hematoma was not considered to be one of the possible diagnoses of unknown intra-abdominal tumor because of the poor recognition resulting from rarity of this disease. The case demonstrated neither active bleeding nor complaints of significant symptoms, and laparotomy was not thought to be an inevitable approach. Greater awareness of this disease is needed. The mechanisms of the hematoma in the present case remain unknown. The case did not have any causative factors. Histological examination also revealed no abnormality leading to intramural bleeding. The mass was located at the transverse colon near the splenic flexure, and interestingly it adhered to the descending colon on the

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Table 1 Intramural hematoma of the colon Reference

Year

Age

Sex

Site

Etiology

Treatment

Result

Kratzer and Dixon [9]

1951

70

M

Ascending

Trauma

Operation

Cured

Adams-Ray and Sundstrom [10]

1955

62

M

Ascending

Foreign body

Operation

Cured

Hess [23]

1964

61

F

Transverse

Trauma

Operation

Cured

Nance and Crowder [25]

1968

29

M

Cecum

Trauma

Operation

Cured

Calenoff and Lounsbury [6]

1969

64

M

Sigmoid

?

Operation

Cured

Stewart et al. [26]

1970

13

M

Transverse

Trauma

Operation

Cured

Wynn [27]

1971

24

F

Sigmoid

Endometriosis

Operation

Cured

Schiller et al. [4]

1971

9

M

Sigmoid

Factor X deficiency

Conservative

Cured

Harrison et al. [7]

1972

36

M

Sigmoid

Hemophilia

Operation

Cured

Pates et al. [5]

1973

70

F

Hepatic flexure

Warfarin therapy

Operation

Cured

Esposito [28] Westcott and Smith [11]

1973 1975

28 55

F M

Sigmoid Sigmoid-descending junction

Complication of laparoscopy Trauma

Conservative Operation

Cured Cured

Kahn et al. [12]

1977

9

M

Descending

Hemophilia

Conservative

Cured

Jeffrey et al. [16]

1982

33

?

Cecum, ascending

Trauma

Operation

Cured

Yoshida et al. [13]

1983

54

M

Descending, sigmoid

Amyloidosis

Operation

Died

Welling and Reilly [14]

1986

17

M

Ascending

Trauma

Conservative

Cured

Berezin et al. [29]

1992

13

M

Splenic flexure

Trauma

Conservative

Cured

Berezin et al. [29]

1992

6

M

Sigmoid

Trauma

Conservative

Cured

Sachdeva et al. [21]

1994

3

M

Transverse

Trauma

Conservative

Cured

Yin et al. [18]

2000

37

M

Cecum, ascending

Trauma

Operation

Cured

Vollmer et al. [17]

2000

38

M

Ascend

Trauma

Operation

Cured

Sousa et al. [22]

2000

32

M

Sigmoid, descending

Hemophilia

Conservative

Cured

Karjoo et al. [15]

2000

9

M

Descending

Trauma

Conservative

Cured

Dixon et al. [30]

2000

29

M

Cecum

Trauma

Conservative

Cured

Calabuig et al. [19]

2002

21

M

Cecum, ascending

Trauma

Operation

Cured

Calabuig et al. [19]

2002

33

M

Cecum, ascending

Trauma

Operation

Cured

Nakayama et al. [8] Umeda et al. [2]

2006 2007

65 19

M M

Cecum Descending

Hemophilia ?

Operation Operation

Cured Cured

Jarry et al. [3]

2008

Present case

55

M

Sigmoid

Hemophilia

Operation

Cured

82

M

Transverse

?

Operation

Cured

M male, F female

serosal side. Although the cause of this adhesion was unknown, under this condition, the colonic wall might have been pulled and stretched with bowel movement, which could have sheared the layer of the colonic wall and torn the vessels of the muscularis. This scenario is one of the plausible explanations for the pathogenesis in the present case. Since only a few cases of idiopathic colonic hematoma have been reported so far, it is still premature to assume that the clinical features and pathogenesis of this disease are precisely understood. Further survey is warranted. In summary, intramural colonic hematoma is a rare condition, and it is mostly associated with trauma and bleeding tendency. Idiopathic cases are very rare but physicians should consider this disease as one of the differential diagnoses of an unknown intra-abdominal tumor. Surgery is a common approach, but unnecessary surgical

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treatment can be avoided by greater awareness of this disease and accurate diagnosis.

References 1. Hughes CE, Conn J, Sherman JO. Intramural hematoma of the gastrointestinal tract. Am J Surg. 1977;133:276–9. 2. Umeda I, Ohta H, Doi T, Nobuoka A, Kanisawa Y, Kawasaki R, et al. Idiopathic intramural hematoma of the colon. Gastrointest Endosc. 2007;66:861–4. 3. Jarry J, Biscay D, Lepront D, Rullier A, Midy D. Spontaneous intramural haematoma of the sigmoid colon causing acute intestinal obstruction in a haemophiliac: report of a case. Haemophilia. 2008;14:383–4. 4. Schiller M, Morse TS, Frye TR. Severe rectal bleeding from an intramural hematoma of the sigmoid. Pediatrics. 1971;48:146–8. 5. Pates DR, Shrivastav R, Hand G. Intestinal obstruction due to intramural hematoma of the colon, a complication of sodium

Clin J Gastroenterol (2009) 2:161–165

6. 7.

8.

9.

10.

11. 12.

13.

14.

15.

16.

17.

warfarin therapy: report of a case. Dis Colon Rectum. 1973;16:416–8. Calenoff L, Lounsbury F. Intramural hematoma of the sigmoid. Am J Roentgenol Radium Ther Nucl Med. 1969;107:170–4. Harrison HC, Lord RS, Chesterman CN, Biggs JC, Tracy GD. Spontaneous intramural haematoma in the sigmoid colon of a haemophiliac. Aust N Z J Surg. 1972;42:69–70. Nakayama Y, Fukushima M, Sakai M, Hisano T, Nagata N, Shirahata A, et al. Intramural hematoma of the cecum as the lead point of intussusception in an elderly patient with hemophilia A: report of a case. Surg Today. 2006;36:563–5. Kratzer GL, Dixon CF. Traumatic submucosal hematoma of the midportion of the ascending colon; report of case. Proc Staff Meet Mayo Clin. 1951;26:18–20. Adams-Ray J, Sundstrom KA. Stenosing hematoma of the colon, possibly due to testa of pea lodged in the intestinal wall: a case report. Acta Chir Scand. 1955;108:398–401. Westcott JL, Smith JR. Mesentsery and colon injuries secondary to blunt trauma. Radiology. 1975;114:597–600. Kahn A, Vandenbogaert N, Cremer N, Fondu P. Intramural hematoma of the alimentary tract in two hemophilic children. Helv Paediatr Acta. 1977;31:503–7. Yoshida T, Kanbe H, Haraguchi Y, Sakamoto A, Iwashita T, Tanaka K, et al. Submucosal hematoma producing mechanical obstruction in the sigmoid colon, complicated by systemic amyloidosis. Endoscopy. 1983;15:277–80. Welling RE, Reilly PS. Nonoperative treatment of a traumatic intramural hematoma of the ascending colon. South Med J. 1986;79:1309–10. Karjoo M, Domachowske J, Trust S. Intramural hematoma of the descending colon after blunt abdominal trauma. Clin Pediatr (Phila). 2000;39:373–4. Jeffrey RB, Federle MP, Stein SM, Crass RA. Case report. Intramural hematoma of the cecum following blunt trauma. J Comput Assist Tomogr. 1982;6:404–5. Vollmer CM Jr, Schmieg RE, Freeman BD, Balfe DM. Traumatic colonic hematoma. J Trauma. 2000;49:1155.

165 18. Yin WY, Gueng MK, Huang SM, Chen HT, Chang TM. Acute colonic intramural hematoma due to blunt abdominal trauma. Int Surg. 2000;85:51–4. 19. Calabuig R, Ortiz C, Sueiras A, Vallet J, Pi F. Intramural hematoma of the cecum: report of two cases. Dis Colon Rectum. 2002;45:564–6. 20. Parizel PM, Makkat S, Van Miert E, Van Goethem JW, van den Hauwe L, De Schepper AM. Intracranial hemorrhage: principles of CT and MRI interpretation. Eur Radiol. 2001;11:1770–83. 21. Sachdeva RS, Jaeger A, Norton K, Raucher H, Dolgin SE, Benkov K, et al. Intramural hematoma of the transverse colon in battered child syndrome. J Pediatr Gastroenterol Nutr. 1994;18: 111–3. 22. Sousa C, Pedroto I, Campos M, Pinho C. Spontaneous hematoma of the colon. Endoscopy. 2000;32:S74. 23. Hess RA. Intramural hematoma of the transverse colon with obstruction and possible impending gangrene: report of a case associated with acute hemorrhagic cholecystitis. Am Surg. 1964;30:138–40. 24. Richards M, Jarvis MJ, Thompson N, Wadsworth ME. Cigarette smoking and cognitive decline in midlife: evidence from a prospective birth cohort study. Am J Public Health. 2003;93:994–8. 25. Nance FC, Crowder VH. Intramural hematoma of the colon following blunt trauma to the abdomen. Am Surg. 1968;34:85–7. 26. Stewart DR, Byrd CL, Schuster SR. Intramural hematomas of the alimentary tract in children. Surgery. 1970;68:550–7. 27. Wynn TE. Endometriosis of the sigmoid colon. Massive intramural hematoma. Arch Pathol. 1971;92:24–7. 28. Esposito JM. Hematoma of the sigmoid colon as a complication of laparoscopy. Am J Obstet Gynecol. 1973;117:581–2. 29. Berezin S, Glassman MS, Slim MS, Newman LJ. Colonic hematoma after blunt abdominal trauma. J Pediatr Gastroenterol Nutr. 1992;15:100–2. 30. Dixon E, Steed B, Sutherland F, Mitchell P. Soft-tissue case 32. Right colonic intramural hematoma. Can J Surg. 2000;43(90):112.

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

An 82-year-old man visited our hospital for abdominal discomfort and constipation lasting 3 days. He did not have a history of trauma or bleeding tend...
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