- Email: [email protected]
An Unusual Cause of Lower Gastrointestinal Bleeding
Accepted Manuscript An unusual cause of lower gastrointestinal bleeding Elisa Gravito-Soares, Marta Gravito-Soares, Pedro Figueiredo
PII: DOI: Reference:
S0016-5085(17)36173-5 10.1053/j.gastro.2017.09.014 YGAST 61436
To appear in: Gastroenterology Accepted Date: 15 September 2017 Please cite this article as: Gravito-Soares E, Gravito-Soares M, Figueiredo P, An unusual cause of lower gastrointestinal bleeding, Gastroenterology (2017), doi: 10.1053/j.gastro.2017.09.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT An unusual cause of lower gastrointestinal bleeding 1
1
1,2
Elisa Gravito-Soares , Marta Gravito-Soares , Pedro Figueiredo 1
Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra,
Portugal Faculty of Medicine, University of Coimbra, Coimbra, Portugal
Elisa Gravito-Soares, Centro Hospitalar e Universitário de Coimbra;
SC
Corresponding author:
RI PT
2
e-mail: [email protected]
M AN U
Praceta Professor Mota Pinto, 3000-075 Coimbra, Portugal;
Telephone: (+351)919902976; Fax number: 239701517
Conflicts of interest (finantial, professional or personal): None to declare
TE D
Informed consent: The informed consent was obtained for this case report Short title: An unusual cause of lower gastrointestinal bleeding Word count: 450
EP
Grant support: None to declare Author’s contributions:
AC C
Elisa Gravito-Soares and Marta Gravito-Soares contributed equally, writing the manuscript and reviewing the literature. Elisa Gravito-Soares is the article guarantor. Pedro Figueiredo reviewed the manuscript.
ACCEPTED MANUSCRIPT Question: A 64-year-old woman with medical history of atrial fibrillation undergoing anticoagulation with Dabigatran, hypertension and dyslipidemia, presented at the emergency department with 12-hours history of sudden abdominal pain and hematochezia. No history of abdominal trauma, fall or bleeding diathesis. She had a total colonoscopy with no lesions 3 months ago. On physical examination, the patient had hemodynamic stability, mild paleness of
RI PT
the mucosae and skin, mild left-lower quadrant abdominal discomfort and fresh blood on digital rectal examination. Laboratory evaluation was remarkable for mild normochromic normocytic anemia (hemoglobin 11.5g/dL, normal platelet count (230,000/µL) normal INR (1.29), prolonged
SC
aPTT (55.9seconds; normal range:25-34) and no elevation of inflammatory parameters. A colonoscopy was performed showing a protruding dark brownish-red lesion occupying approximately half of the luminal circumference with some fresh blood in the lumen, between 40
M AN U
and 45cm from anal verge (Figures A,B,C).
AC C
EP
TE D
What is the diagnosis?
ACCEPTED MANUSCRIPT Answer: Non-traumatic spontaneous hematoma of the distal descending colon ®
It was decided to perform a lower echo-endoscopy (PENTAX Medical radial EUS) showing a fusiform hypoechoic lesion of the submucosa with no invasion of muscular layer, no internal vascularization, measuring 24.5x6mm in a cross-section, and occupying approximately one
RI PT
third of the luminal circumference at the distal descending colon (Figures D,E). This clinical, endoscopic and ultrasonographic features are compatible with a spontaneous hematoma of the distal descending colon facilitated by anticoagulant therapy. A conservative approach was applied with bowel rest and fluid therapy. Anticoagulation was withdrawn and low molecular
SC
weight heparin was started as a replacement given thrombotic risk. The patient had an unremarkable clinical course, without needing blood transfusion. Few months later, a revision
M AN U
colonoscopy showed mucosal detachment with underlying ulceration (Figures F,G,H), whose biopsies revealed reactive changes, foci of cryptic coagulation necrosis, and edema and congestion of the lamina propria.
Non-traumatic spontaneous intramural hematoma of the gastrointestinal tract is a rare 1,2
clinical condition, usually arising in the small bowel. Colon involvement is relatively rare. 1,2
TE D
factors include bleeding diathesis and anticoagulation.
Risk
Endoscopic and imaging diagnosis 1,2
involve the identification of a localized, well-defined and intramural mass.
Conservative
therapy with anticoagulation withdrawal represents the main approach, being surgery reserved 1,2
We report a case of spontaneous hematoma of the descending
EP
for complicated/severe cases.
colon facilitated by chronic anticoagulation. Several cases of gastrointestinal hematoma
AC C
associated with antiplatelet and anticoagulant agents have been reported previously. To our knowledge, however, this is the second case of colonic hematoma being reported for the new 3
oral anticoagulant therapy. An intramural hematoma should be considered in the differential diagnosis of patients undergoing anticoagulation, with abdominal pain and lower gastrointestinal bleeding. If absence of brisk/massive bleeding and accessible location of the lesion, echoendoscopy may help to establish the diagnosis of intramural hematoma, avoiding imaging requiring radiation.
ACCEPTED MANUSCRIPT References 1. Kones O, Dural AC, Gonenc M, et al. Intramural hematomas of the gastrointestinal system: a 5-year
single
center
experience.
J
Korean
Surg
Soc
2013;85(2):58-62.
doi:
10.4174/jkss.2013.85.2.58.
RI PT
2. Abdel Samie A, Theilmann L. Risk factors and management of anticoagulated-induced intramural hematoma of the gastrointestinal tract. Eur J Trauma Emerg Surg 2013;39(2):191194. doi: 10.1007/s00068-013-0250-1.
SC
3. Kusanaga M, Aridome G, Hayashi H, et al. A case of submucosal hematoma of the colon: A
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EP
TE D
M AN U
complication of dabigatran therapy. Dig endosc 2015;57(6):1373-1377.
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PII: DOI: Reference:
S0016-5085(17)36173-5 10.1053/j.gastro.2017.09.014 YGAST 61436
To appear in: Gastroenterology Accepted Date: 15 September 2017 Please cite this article as: Gravito-Soares E, Gravito-Soares M, Figueiredo P, An unusual cause of lower gastrointestinal bleeding, Gastroenterology (2017), doi: 10.1053/j.gastro.2017.09.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT An unusual cause of lower gastrointestinal bleeding 1
1
1,2
Elisa Gravito-Soares , Marta Gravito-Soares , Pedro Figueiredo 1
Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra,
Portugal Faculty of Medicine, University of Coimbra, Coimbra, Portugal
Elisa Gravito-Soares, Centro Hospitalar e Universitário de Coimbra;
SC
Corresponding author:
RI PT
2
e-mail: [email protected]
M AN U
Praceta Professor Mota Pinto, 3000-075 Coimbra, Portugal;
Telephone: (+351)919902976; Fax number: 239701517
Conflicts of interest (finantial, professional or personal): None to declare
TE D
Informed consent: The informed consent was obtained for this case report Short title: An unusual cause of lower gastrointestinal bleeding Word count: 450
EP
Grant support: None to declare Author’s contributions:
AC C
Elisa Gravito-Soares and Marta Gravito-Soares contributed equally, writing the manuscript and reviewing the literature. Elisa Gravito-Soares is the article guarantor. Pedro Figueiredo reviewed the manuscript.
ACCEPTED MANUSCRIPT Question: A 64-year-old woman with medical history of atrial fibrillation undergoing anticoagulation with Dabigatran, hypertension and dyslipidemia, presented at the emergency department with 12-hours history of sudden abdominal pain and hematochezia. No history of abdominal trauma, fall or bleeding diathesis. She had a total colonoscopy with no lesions 3 months ago. On physical examination, the patient had hemodynamic stability, mild paleness of
RI PT
the mucosae and skin, mild left-lower quadrant abdominal discomfort and fresh blood on digital rectal examination. Laboratory evaluation was remarkable for mild normochromic normocytic anemia (hemoglobin 11.5g/dL, normal platelet count (230,000/µL) normal INR (1.29), prolonged
SC
aPTT (55.9seconds; normal range:25-34) and no elevation of inflammatory parameters. A colonoscopy was performed showing a protruding dark brownish-red lesion occupying approximately half of the luminal circumference with some fresh blood in the lumen, between 40
M AN U
and 45cm from anal verge (Figures A,B,C).
AC C
EP
TE D
What is the diagnosis?
ACCEPTED MANUSCRIPT Answer: Non-traumatic spontaneous hematoma of the distal descending colon ®
It was decided to perform a lower echo-endoscopy (PENTAX Medical radial EUS) showing a fusiform hypoechoic lesion of the submucosa with no invasion of muscular layer, no internal vascularization, measuring 24.5x6mm in a cross-section, and occupying approximately one
RI PT
third of the luminal circumference at the distal descending colon (Figures D,E). This clinical, endoscopic and ultrasonographic features are compatible with a spontaneous hematoma of the distal descending colon facilitated by anticoagulant therapy. A conservative approach was applied with bowel rest and fluid therapy. Anticoagulation was withdrawn and low molecular
SC
weight heparin was started as a replacement given thrombotic risk. The patient had an unremarkable clinical course, without needing blood transfusion. Few months later, a revision
M AN U
colonoscopy showed mucosal detachment with underlying ulceration (Figures F,G,H), whose biopsies revealed reactive changes, foci of cryptic coagulation necrosis, and edema and congestion of the lamina propria.
Non-traumatic spontaneous intramural hematoma of the gastrointestinal tract is a rare 1,2
clinical condition, usually arising in the small bowel. Colon involvement is relatively rare. 1,2
TE D
factors include bleeding diathesis and anticoagulation.
Risk
Endoscopic and imaging diagnosis 1,2
involve the identification of a localized, well-defined and intramural mass.
Conservative
therapy with anticoagulation withdrawal represents the main approach, being surgery reserved 1,2
We report a case of spontaneous hematoma of the descending
EP
for complicated/severe cases.
colon facilitated by chronic anticoagulation. Several cases of gastrointestinal hematoma
AC C
associated with antiplatelet and anticoagulant agents have been reported previously. To our knowledge, however, this is the second case of colonic hematoma being reported for the new 3
oral anticoagulant therapy. An intramural hematoma should be considered in the differential diagnosis of patients undergoing anticoagulation, with abdominal pain and lower gastrointestinal bleeding. If absence of brisk/massive bleeding and accessible location of the lesion, echoendoscopy may help to establish the diagnosis of intramural hematoma, avoiding imaging requiring radiation.
ACCEPTED MANUSCRIPT References 1. Kones O, Dural AC, Gonenc M, et al. Intramural hematomas of the gastrointestinal system: a 5-year
single
center
experience.
J
Korean
Surg
Soc
2013;85(2):58-62.
doi:
10.4174/jkss.2013.85.2.58.
RI PT
2. Abdel Samie A, Theilmann L. Risk factors and management of anticoagulated-induced intramural hematoma of the gastrointestinal tract. Eur J Trauma Emerg Surg 2013;39(2):191194. doi: 10.1007/s00068-013-0250-1.
SC
3. Kusanaga M, Aridome G, Hayashi H, et al. A case of submucosal hematoma of the colon: A
AC C
EP
TE D
M AN U
complication of dabigatran therapy. Dig endosc 2015;57(6):1373-1377.
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