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DOI: 10.1055/s-0039-1681787
INTRAMURAL COLONIC HEMATOMA: A RARE COMPLICATION OF ENDOSCOPIC SUBMUCOSAL DISSECTION
Publication History
Publication Date:
18 March 2019 (online)
Intramural colonic hematoma represents a rare complication, following blunt trauma, therapeutic intervention or accompanying diseases with bleeding diathesis.
Here we report the case of a 50-year-old man referred to our unit to perform endoscopic resection of a 35 mm non-polipoyd lesion (non-granular lateral spreading tumor 0-IIa, according to Paris classification) of the descending colon, because of previous positive hemoccult test for colo-rectal cancer screening. The patient didn't refer any comorbidities and an endoscopic submucosal dissection (ESD) was scheduled according to the ESGE guidelines [Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline; Endoscopy 2015; 47 (09): 829 – 854].
ESD was challenging due to persistent bleeding trend, from many submucosal vessels, treated using coagulation with knife (Hybrid-knife T-type, ERBE Gmbh), through-the-scope (TTS) clips, epinephrine injection, hemostatic monopolar forceps and finally with hemostatic idrogel (Purastat).
Three hours after the procedure, the patient became hemodynamically instable, with copious enterorrhagia. So, after initial resuscitation, urgent colonoscopy was performed, showing arterial bleeding from resection bed, stopped by TTS clips deployment. However, a voluminous 8 cm intramural hematoma has been developed; so, an urgent surgical intervention was required.
Laparotomy confirmed intramural hematoma along the descending colon and sigma, starting distal to the resection bed, with hemoperitoneum from colon fissuration. Surgical resection was performed and the patient was discharged home one week later. However, during surgical intervention, a hemorrhagic trend was observed. Further analysis revealed deficit factor V Leiden.
In conclusion, intramural hematoma is a rare but potentially life-threating complication after endoscopic resections, especially in high-risk procedures (ESD) or patients (i.e. patients with bleeding diathesis or with ongoing anti-thrombotic therapies). Before therapeutic procedures, we advise to accurately investigate any possible signs of bleeding diathesis (i.e. frequent epistaxis).