Intramural hematoma of the colon caused by double-balloon enteroscopy in a patient with chronic disseminated intravascular coagulation

A 63-year-old man with a history of surgery for thoracic aortic dissection was transferred to our hospital with obscure gastrointestinal bleeding (OGIB) and bloody stools. Laboratory examination revealed the following results: hemoglobin, 9.9 g/dL; platelets, 94 000/µL; creatinine, 1.29 mg/dL. Video capsule endoscopy following anterograde and retrograde double-balloon enteroscopy (DBE) could not identify the bleeding source.

Fresh bloody stools recurred 4 days after the resumption of feeding and the patient required transfusion. Emergency colonoscopy revealed an intramural hematoma in the sigmoid colon, with rupture and bleeding into the surrounding mucosa ([Fig. 1]). Contrast-enhanced computed tomography (CT) revealed a dissection of the abdominal aorta ([Fig. 2]). Laboratory data indicated disseminated intravascular coagulation (DIC): platelets, 96 000/µL; prothrombin time, 13.5 seconds; fibrinogen, 69 mg/dL; fibrin/fibrinogen degradation products, 105 µg/dL; D-dimer, 99 µg/dL; plasmin-α₂-plasmin inhibitor complex, 11.4 µg/mL; thrombin-antithrombin III complex, 49.5 ng/mL. We diagnosed an intramural hematoma of the colon due to chronic DIC associated with aortic dissection.

Fig. 1 Views during emergency colonoscopy showing an intramural hematoma at the junction of the descending and sigmoid colon, with rupture and bleeding into the surrounding mucosa.

Fig. 2 Contrast-enhanced computed tomography (CT) scans showing an aortic dissection running from: a the ascending aorta to; b the abdominal aorta, along with a mass partially obstructing the sigmoid colon (yellow arrow).

The patient was not a candidate for surgery for the aortic dissection because of his comorbidities. Continuous intravenous heparin (15 000 units/day) improved the laboratory abnormalities. Follow-up colonoscopy 16 days after the initial treatment showed healing ulceration ([Fig. 3]). The patient was changed to oral warfarin, following which no recurrent bleeding was observed.

Fig. 3 Follow-up colonoscopy showing improvement of the hematoma and healing ulceration 16 days after treatment.

Bleeding associated with DBE is rare and mostly follows polypectomy or biopsy [1]. Intramural hematoma of the colon is rare but can be the result of blunt trauma typically in the presence of anticoagulant therapy or other hematologic disease [2]. In this case, DBE compressed the mucosa, resulting in an intramural hematoma of the colon, under conditions of chronic DIC, which is a rare finding often associated with aortic aneurysm and dissection [3]. Surgery is the primary treatment to eliminate the cause but heparin has been reported to treat chronic DIC effectively [3]. We recommend careful examination of coagulation studies prior to DBE in patients with OGIB and an aortic aneurysm or dissection.

Endoscopy_UCTN_Code_CPL_1AI_2AD

Competing interests: None

• References

• 1 Nakayama S, Tominaga K, Obayashi T et al. The prevalence of adverse events associated with double-balloon enteroscopy from a single-centre dataset in Japan. Dig Liver Dis 2014; 46: 706-709
• 2 Liu Y, Yang S, Tong Q. Spontaneous intramural hematoma of colon. Clin Gastroenterol Hepatol 2012; 10: e38
• 3 Yamamoto K, Ito H, Hiraiwa T et al. Effects of nafamostat mesilate on coagulopathy with chronic aortic dissection. Ann Thorac Surg 2009; 88: 1331-1333