title: Spontaneous intramural hematoma of rectum in a patient on anticoagulant therapy: case report and review of literature.
abstract: OBJECTIVE
  Gastrointestinal spontaneous hematomas (GSHs) represent 5-10% of patients with acute abdomen. Conservative treatment is the most common approach but the bowel perforation can be a fatal complication. In patients with spontaneous rectal wall hematoma, high comorbidity and abdominal signs of acute abdomen but without radiological signs of intestinal perforation, an early exploratory laparotomy should be considered.
  
  
  METHODS
  A 70-year-old man with severe dilatative cardiomyopathy and chronic obstructive pulmonary disease (COPD) on anticoagulant therapy was admitted with acute abdominal pain and anemia. An abdominal CT scan showed a perihepatic, perisplenic and parietocolic effusion associated with a retro-rectal hematoma measuring 6 × 6 × 14 cm without signs of active bleeding. Because of sudden onset of signs of peritonitis, a laparotomy was performed which showed an ischemic perforation of the sigmoid-rectal junction. We performed a recto-sigmoid resection (Hartmann operation) but the patient died twelve days later for septic shock.
  
  
  CONCLUSIONS
  In patients with GSH the main problem is represented by the choice between conservative and surgical treatment. In case of complications, such as active and persistent intra-abdominal bleeding, wall ischemia with or without bowel perforation and peritonitis, surgical treatment is mandatory. The absence of radiological signs of perforation can cause a delay of surgical treatment with unfavourable outcome especially in patient with rectal hematoma and severe comorbidity.
  
  
  CONCLUSIONS
  GSHs of rectum are uncommon but a strict clinical monitoring is crucial because the extraperitoneal position make it possible a late clinical or radiological identification of perforation and a late laparotomy.
authors.forename: Adolfo Antonio
authors.initials: AA
authors.lastname: Rogano
authors.forename: Roberto
authors.initials: R
authors.lastname: Caronna
authors.forename: Cosimo Gabriele
authors.initials: CG
authors.lastname: Russillo
authors.forename: Roberto Luca
authors.initials: RL
authors.lastname: Meniconi
authors.forename: Emanuele
authors.initials: E
authors.lastname: Casciani
authors.forename: Denise
authors.initials: D
authors.lastname: Coniglio
authors.forename: Alessandra
authors.initials: A
authors.lastname: Pulvirenti
authors.forename: Annunziata
authors.initials: A
authors.lastname: Martellucci
authors.forename: Piero
authors.initials: P
authors.lastname: Chirletti
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects*; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced*; D006406:Hematoma / Q000139:chemically induced*; D006801:Humans; D008297:Male; D012002:Rectal Diseases / Q000139:chemically induced*; D014859:Warfarin / Q000009:adverse effects*
chemical_list: D000925:Anticoagulants; D014859:Warfarin