Endoscopic diagnosis and conservative management of an intramural sigmoid haematoma complicating anticoagulant therapy

We describe the case of a 63-year old man with a sigmoid intramural haematoma caused by anticoagulant therapy with acenocoumarol and we review the related literature. He presented to the emergency department complaining of haematochezia and colicky lower abdominal pain. He was on regular acenocoumarol 2 mg daily for a previous acute myocardial infarction two years earlier. He also took 500 mg of aspirin the day before admission. He was apyrexial, the blood pressure was 95/60 mmHg, and the pulse rate 86/min irregular. There was tenderness in the left iliac fossa and the bowel sounds were increased. The digital rectal examination showed blood stained liquid only. After a failed attempt to put an intravenous canula, a large haematoma developed in his right arm. The INR was 6.3. The full blood count showed leucocytosis of 14100/µl (86% neutrophils) and haemoglobin of 14.5 g/dl. Abdominal x-rays after water soluble contrast enema demonstrated partial obstruction of the sigmoid colon. The abdominal CT scan with oral administration of contrast medium showed narrowing of the sigmoid lumen and thickening of the descending and sigmoid colon wall (Fig. 1). The flexible sigmoidoscopy demonstrated an intramural sigmoid colon haematoma partially obstructing the lumen. The acenocoumarol was stopped and the patient was treated with vitamin K, fresh frozen plasma, and intravenous fluids. The next day the INR was 1.47. A new flexible sigmoidoscopy performed four days later showed an oedematous sigmoid colon. However the haematoma had considerably shrunk and the colono- scope could easily reach the splenic flexure. The patient was discharged two days later as the abdominal pain settled and he had a normal bowel movement.