Intramural hematoma of the colon caused by double-balloon enteroscopy in a patient with chronic disseminated intravascular coagulation.

A 63-year-old man with a history of surgery for thoracic aortic dissection was transferred to our hospital with obscure gastrointestinal bleeding (OGIB) and bloody stools. Laboratory examination revealed the following results: hemoglobin, 9.9g/dL; platelets, 94000/μL; creatinine, 1.29mg/dL. Video capsule endoscopy following anterograde and retrograde double-balloon enteroscopy (DBE) could not identify the bleeding source. Fresh bloody stools recurred 4 days after the resumption of feeding and the patient required transfusion. Emergency colonoscopy revealed an intramural hematoma in the sigmoid colon,with rupture andbleeding into the surroundingmucosa (●" Fig.1). Contrast-enhanced computed tomography (CT) revealed a dissection of the abdominal aorta (●" Fig.2). Laboratory data indicated disseminated intravascular coagulation (DIC): platelets, 96000/μL; prothrombin time, 13.5 seconds; fibrinogen, 69mg/dL; fibrin/fibrinogen degradation products, 105μg/dL; D-dimer, 99μg/dL; plasmin-α2-plasmin inhibitor complex, 11.4μg/mL; thrombin-antithrombin III complex, 49.5ng/mL. We diagnosed an intramural hematoma of the colon due to chronic DIC associated with aortic dissection. The patient was not a candidate for surgery for the aortic dissection because of his comorbidities. Continuous intravenous heparin (15000 units/day) improved the laboratory abnormalities. Follow-up colonoscopy 16 days after the initial treatment showed healing ulceration (●" Fig.3). The patient was changed to oral warfarin, following which no recurrent bleeding was observed. Bleeding associated with DBE is rare and mostly follows polypectomy or biopsy [1]. Intramural hematoma of the colon is rare but can be the result of blunt trauma typically in the presence of anticoagulant therapy or other hematologic disease [2]. In this case, DBE compressed the mucosa, resulting in an intramural hematoma of the colon, under conditions of chronic DIC, which is a rare finding often associated with aortic aneurysm and dissection [3]. Surgery is the primary treatment to eliminate the cause but heparin has been reported to treat chronic DIC effectively [3]. We recommend careful examination of coagulation studies prior to DBE in patients with OGIB and an aortic aneurysm or dissection.