older adults with abdominal pain have a six- to eight - fold increase in mortality compared to younger patients [ 1 , 2 ] .
intramural colonic hematomas manifest rarely as complications following blunt traumas or accompanying diseases with bleeding tendency .
a 72-year - old male with cerebral palsy was admitted following development of symptomatic pulmonary embolism for the initiation of therapeutic anticoagulation including heparin drip and oral coumadin .
prior to initiation of therapeutic anticoagulation , he had a computed tomography ( ct ) scan angiogram of his chest , abdomen and pelvis .
a pulmonary embolism and large stool burden were noted on the ct scan and tap water enemas were initiated following the start of the heparin drip and coumadin initiation ( fig .
a complete blood count demonstrated an acute drop in hemoglobin from 12 to 6 , partial thromboplastin time 100 and international normalized ratio was 3.5 .
the patient was transfused 2 units packed red blood cells , but his hemoglobin did not increase . on exam there was also some new mucoid blood drainage and abdominal tenderness with distension .
a repeat ct scan angiogram demonstrated a 15  6  3 cm abdominal intramural hematoma ( fig .
given the increasing abdominal pain and concern for perforation as well as lack of response to blood products , an exploratory laparotomy was performed . at laparotomy
a 30  15 cm abdominal recto - sigmoid hematoma was discovered distending the previously capacious bowel wall without perforation ( fig .
large clamps were used to transect the distal bowel at the recto - sigmoid junction and the area of transection was oversewn .
it is likely that dilated colon allowed for a large amount of hematoma to accumulate .
the patient recovered post - operatively and was discharged following return of bowel function . following the operation on postoperative day 1 coagulation was resumed without any additional issues . 

figure 1:ct  abdomen and pelvis with intravenous contrast . admission imaging demonstrating large colonic stool burden in the axial ( a ) , coronal ( b ) and sagittal orientation ( c ) .
ct abdomen and pelvis following enema demonstrating large colonic wall hematoma axial ( d ) , coronal ( e ) and sagittal orientation ( f ) . 

figure 2:intraoperative photograph of the large intramural hematoma of the sigmoid colon descending into the recto - sigmoid junction . 

admission imaging demonstrating large colonic stool burden in the axial ( a ) , coronal ( b ) and sagittal orientation ( c ) .
ct abdomen and pelvis following enema demonstrating large colonic wall hematoma axial ( d ) , coronal ( e ) and sagittal orientation ( f ) .
intraoperative photograph of the large intramural hematoma of the sigmoid colon descending into the recto - sigmoid junction .
intramural hematomas of the alimentary tract are uncommon , occurring most frequently in the setting of blunt abdominal trauma ( duodenum most common , colon least common ) , and in 1536% are spontaneous in patients with underlying hematologic disease or on anticoagulant therapy .
the incidence of all bleeding complications during anticoagulation therapy ranges from 5 of 48% , but gastrointestinal hemorrhage occurs in only 2 to 4% of patients .
small bowel hematoma has an incidence of 1 case per 2500 anticoagulated patients per year , while large bowel hematomas have an even lower incidence in the literature .
gastrointestinal complications following anticoagulation can present with bleeding into the intestinal lumen , usually related to some underlying mucosal abnormality , retroperitoneal hemorrhage or bleeding into intra - abdominal organs ; less common are intramural hematomas .
rectal hematoma and subsequent perforation have been described in patients following enemas and radiographic contrast enemas   due to both instrumentation and hydrostatic pressure .
one study demonstrated that the incidence of iatrogenic large bowel perforations ranges from 0.1 to 0.9% following colonoscopy and barium enemas .
the differential diagnosis of abdominal pain for a patient on anticoagulation is broad including rectus sheath hematoma , retroperitoneal hematoma , intestinal / mesenteric hematoma , bleeding diverticula and rectal trauma from enema or foreign object .
the use of ct as the first imaging modality in the evaluation of patients with acute abdominal complaints especially in the elderly population .
ct characteristics of colonic hematoma include circumferential wall thickening , intramural hyper - density , luminal narrowing and intestinal obstruction .
additional adjuncts for diagnosis consist of rigid proctoscopy which demonstrate colonic intramural hematomas as round shaped , dark reddish submucosal masses often obstructing the luminal space . for patients with intramural hematomas
conservative management includes removing the anticoagulation therapy , correcting coagulopathy , intestinal decompression and avoiding oral intake while awaiting spontaneous resorption of the hematoma .
the challenge is to distinguish patients with self - limiting intramural hematoma from those with more severe pathology .
conventional physical exam signs are inadequate to distinguish more ill patients as even a simple hematoma may also present with high fevers , leukocytosis and rebound tenderness . if the intramural hematoma causes obstruction or if the cause of the bowel obstruction is unknown , surgical intervention for colonic hematoma is warranted .
drainage of the hematoma may increase the risk of serious infection as it introduces bacteria to a previously sterile hematoma .
a review of the literature demonstrates a shift in the management of colonic hematomas over the past 50 years .
cases prior to 1969 were most commonly treated with surgical intervention . however , following 2010 they were managed more frequently conservatively .
treatment of colonic hematomas depends on symptoms and clinical findings [ 11 , 14 ] .
overall bowel obstruction in a patient on anticoagulation with acute abdominal pain results in operative exploration in 67% ( 42 of 51 patients ) . for those reasons
indications for immediate surgical intervention include active and persistent intra - abdominal bleeding , intestinal wall ischemia with or without bowel perforation and peritonitis .
many case series and reports have demonstrated that patients with distal colonic hematomas required diverting colostomies 80% of the time .
endoscopic drainage requires colonic wall viability   but could result in relief of the  tamponade effect of the hematoma .
selective mesenteric embolization can be performed in patients with an active blush into the colonic wall with an 85% success rate , and an overall 20% of complication as a result of the procedure .
recto - sigmoid hematomas should be considered as a diagnosis for a patient with a dropping hemoglobin and abdominal pain in the setting of an enema on therapeutic anticoagulation .
if obvious signs of clinical deterioration such as free air and failure to respond to correction of coagulation are identified , then operative intervention should commence .
the authors declare that there is no conflict of interests regarding the publication of this paper .
 causes of colonic and recto - sigmoid hematomas are multifactorial . 
 patients can present with a combination of dropping hemoglobin , bowel obstruction and perforation . 
 computed tomography imaging can provide clues to a diagnosis of intramural hematoma . 
 we present a case of rectal hematoma and a review of current management literature . 
 a 72-year - old male on therapeutic anticoagulation for a pulmonary embolism , was administered an enema resulting in severe abdominal pain unresponsive to blood transfusion . 
 a sigmoid colectomy with end colostomy was performed . 
 although rare , colonic and recto - sigmoid hematomas should be considered as a possible diagnosis for adults with abdominal pain on anticoagulant therapy . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONFLICT OF INTEREST STATEMENT