Date Published: July 11, 2019
Publisher: Wolters Kluwer
Author(s): Aleksandar Gavrić, Rok Dežman, Sebastian Stefanović, Jan Drnovšek, Borut Štabuc.
Intramural hematoma of the colon is a rare complication of colonoscopy. We present a case of a 78-year-old woman on warfarin who presented with hematochezia and hypotension due to intramural hematoma of the sigmoid colon after colonoscopy with polypectomy of small polyps in the right colon.
Intramural hematoma of the gastrointestinal (GI) tract is rare and is least common in the colon.1 The main causes are trauma, anticoagulation therapy, and hematologic disorders. Spontaneous hematomas of unknown etiology have also been described.1–4 Only a few cases after diagnostic lower GI endoscopy without or with polypectomy have been published.5–9 Antithrombotic therapy and a redundant sigmoid colon, which often results in a difficult endoscopic procedure, looping, and requirements for increased external abdominal pressure are the main risk factors for a colonic hematoma after colonoscopy.1,5 Patients most commonly present with abdominal pain and hematochezia.10 Diagnosis is confirmed with colonoscopy and abdominal contrast-enhanced computed tomography.10 Initially, conservative therapy is indicated, but when symptoms persist, surgical resection is required.10 A fatal clinical outcome is rare.9
A 78-year-old woman with a medical history of congestive heart failure, pacemaker implantation due to iatrogenic atrioventricular block after heart surgery, anticoagulant therapy with warfarin for a mechanical aortic and mitral valve, chronic kidney disease stage III, arterial hypertension, and with no history of abdominal surgery was admitted due to hematochezia that had started a few hours earlier. Three days previously, she had a colonoscopy for a further diagnostic workup of microcytic anemia. The endoscopic procedure was difficult due to a redundant sigmoid colon. As a result, increased external abdominal pressure was applied to reach the cecum. The procedure was prolonged; the total procedural time was 75 minutes. CO2 was used for insufflation.
Hematomas have been reported to occur in all parts of the GI tract but are least common in the colon.1,11 The estimated incidence of GI hematomas in anticoagulated patients is 1 in 250,000.4 The main causes are trauma, anticoagulation therapy, and hematologic disorders. Spontaneous hematomas of unknown etiology have also been described in the literature.1–4 Only a few cases after diagnostic lower GI endoscopy without or with polypectomy have been published.5–9 The common feature in almost all described cases is a difficult and long colonoscopy due to a redundant colon.
Author contributions: A. Gavrić wrote and reviewed the manuscript. R. Dežman reviewed the manuscript and provided and commented CT images. S. Stefanović, J. Drnovšek, and B. Štabuc reviewed the manuscript. A. Gavrić is the article guarantor.