If bleeding GI, induced by anticoagulants are frequent, intramural hematomas and mesenteric are rarer and their topography is preferred proximal duodenum, jejunum and above. The locations colic, especially sigmoid, are exceptional [1].
MSM, 43 years, chronic hemodialysis for five years, carrying a mechanical prosthetic mitral past three years and on long term anticoagulant therapy (Coumadin 4 mg / day) was admitted in March 2005 at the emergency department for pelvic pain lasting for a week, which had worsened, and generalized throughout the abdomen in a few hours with the appearance of syncope.
The examination revealed a state of shock with systolic blood pressure 70 mm Hg and a diastolic of 50 mmHg, profuse sweating, cold extremities and a significant mucocutaneous pallor. Abdominal palpation a tender mass in the left iliac fossa, ill-defined and mobile associated with distention and tenderness of the rest of the abdomen with dullness Slope.
The DRE revealed an melaena. Laboratory tests showed microcytic hypochromic anemia at 6 g / dl of hemoglobin and prothrombin time to 35% with an INR of 2.5. Abdominal ultrasound showed a peritoneal effusion of great abundance and a sigmoid wall thickening with anechoic halo périsigmoïdien.
urgent laparotomy was decided after a brief resuscitation and showed an abundance of hemoperitoneum and a hematoma of the sigmoid cracked and extended to the wall of the sigmoid (Fig. 1). Resection with double stoma was performed (Fig. 2). The postoperative course was uneventful. The restoration of gastrointestinal continuity was performed two months later. Examination histological part of colectomy showed the presence of a hemorrhagic collection at the mesocolon, which was leaking into the colonic subserosa, causing a detachment of the serosa. Elsewhere, there was a very congested in the mucosa and submucosa compared with no other associated injury, particularly vascular.
intramural hematomas can occur throughout the digestive tract. Trauma, hemophilia and anticoagulant therapy are the main causes. Cases of spontaneous hematomas were also reported
[2]. The most common are those located at of the small intestine and duodenum [3,4]. Hematoma of the colon and particularly those induced by anticoagulant therapy are very exceptional. Twelve cases are reported in the literature with only four locations sigmoid [1]. In association with bleeding and intraparietal intramésentérique may appear intraluminal bleeding, intra-or retroperitoneal [4].
abdominal pain and intestinal obstruction in general partial, are common symptoms. The INR is often increased beyond the therapeutic ranges. However, anticoagulants may be responsible intramural hematoma with an INR slightly increased or even normal [1]. Our patient presented without any context traumatic hematoma of the sigmoid mesocolon, associated with intraluminal hemorrhage, intramural and intraperitoneal responsible melaena, with hemoperitoneum, abdominal pain and hemodynamic instability. Oral anticoagulant therapy, although not overdosed, seems to be the cause.
The ground terminal chronic renal insufficiency presented our patient is not associated with coagulopathy, but may nevertheless be responsible for vascular fragility.
diagnosis based on ultrasound, CT and endoscopy [1]. The sonographic appearances of the hematoma are variable in time. Usually the fee is anechoic hematoma. Training and the gradual fragmentation of the clot explain the appearance of internal echoes and the existence of inconsistent type septal structures [5]. The CT appearance of the hematoma also varies over time. Recently, it appears spontaneously hyperdense, becoming isodense and then, finally, hypodense [4]. The management of the hematoma the sigmoid depends on the tolerance of the patient.
Conservative treatment includes aspiration digestive gastric tube in the presence of bowel obstruction, blood transfusion and correction of the state of hypocoagulability by administering low doses of vitamin K and fresh frozen plasma, while avoiding lead hypercoagulability may lead to thrombosis in patients with cardiovascular disease.
However, although most authors advocate conservative treatment in five of the 12 observations cited, surgery was necessary. The surgical approach was motivated by the rupture of the hematoma, abscess formation, abdominal pain and uncontrollable diagnostic uncertainty [1].
mesosigmoid The hematoma induced by anticoagulant during short is exceptional. Its diagnosis is based on ultrasonography and abdominal CT scan. Conservative treatment should be first-line setting. Surgical treatment is reserved for complicated shapes.
References
[1] Trompetas V, Yettimis E, Varsamidakis N, Courcoutsakis N, Kalokairinos E. Endoscopic diagnosis and conservative management of an intramural sigmoid haematoma complicating anticoagulant therapy. Acta Gastroenterol Belg 2007;70:313—5.
[2] Umeda I, Ohta H, Doi T, Nobuoka A, Kanisawa Y, Kawasaki R, et al. Idiopathic intramural hematoma of the colon. Gastrointest Endosc 2007;66:861—4.
[3] Hughes III CE, Conn J, Sherman JO. Intramural hematoma of the gastrointestinal tract. Am J Surg 1977;133:276—9.
[4] Abbas MA, Collins JM, Olden KW, Kelly KA. Spontaneous intramural small-bowel hematoma: clinical presentation and long-term outcome. Arch Surg 2002;137:306—10.
[5] Y Thery, Baumont R, Barkat F. Hematoma of the sigmoid mesocolon. About an exceptional case in Niger. J Radiol 1999; 80:312-6.
H. Chtata Department of Cardiovascular Surgery, Military Hospital Mohamed V instruction, Rabat, Morocco
A. * Alahyane Mr. Yaka Service of Visceral Surgery, Military Hospital Mohamed V instruction, Rabat, Morocco Mr.
Oukabli Pathology Service, Military Hospital Mohamed V instruction, Rabat , Morocco
Mr. Taberkant A. Elkirrat Department of Cardiovascular Surgery, Military Hospital Mohamed V instruction, Rabat, Morocco
* Corresponding author. 3 Department of Surgery, Hospital of Auxerre, 2, boulevard de Verdun, 89000 Auxerre Cedex, France.
E-mail: alahyanew@yahoo.fr (A. Alahyane).