E LEVEN cases of intramural hematoma of the colon have been report-ed in the

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1 SEPTEMBER, 1969 INTRAMURAL HEMATOMA OF THE SIGMOID* By LEONID CALENOFF, M.D., and FRANKLIN LOUNSBURY, M.D. CHICAGO, ILLINOIS E LEVEN cases of intramural hematoma of the colon have been report-ed in the literature to date. Eight were included in the 1957 review of Spencer et al.4 of 3 intestinal hematomas. Since then, i case each has been reported by Van De St-adt in I962, Hess in 1964, and Nance and Crowder in I968. An intramural hematoma of the sigmoid was recently demonstrated by barium enema examination and treated surgically at this inst-it-ut-ion. The case had an unique and never before report-ed feature: it- was complicated by intussusception. REPORT OF A CASE A 64 year old retired school teacher came to the Emergency room of Passavant Hospital at 5 :30 P.M. complaining of severe lower abdominal pain and nausea. For the past month he had had daily bowel movements but always felt an incomplete emptying of the rectum. This sensation was accompanied by a bearing down feeling. As a result he started taking daily enemas. At 8:00 A.M. on the day of admission he took a warm water enema as usual. At I I 00 A.M. the lower abdominal pain began. He took another enema but- the pain continued to increase in intensity. During the hours preceding his arrival at the hospital, he made several straining attempts for bowel movement but without success. He was a known hypertensive (175/100), weighed 200 pounds, and was 68 inches in height. He had had a few operations in the past: prostatectomy 4 years before, left inguinal hernia repair 3 years ago and hemorrhoidectomy 2 years ago. On admission, his abdomen was soft-, with good bowel sounds. The suprapubic area was tender and firm. On rectal examination, one examiner described a solid rectal mass, not movable. Another examiner reported a large soft cystic mass in the right lateral aspect of the rectum. Admission blood pressure was 135/85, hemoglobin gm. per 100 ml., hematocrit 44 per cent, and white blood cell count- I 5,400. On proctoscopic examination a large mass looking like a ball of mucus was seen at- 6 cm. The mass was pushed up digitally and the patient experienced relief. The proctoscope was introduced up to 22 cm. The mucosa was dark looking but was intact. It was decided that the case very probably represent-ed a third degree of rectal prolapse, an intrarectal intussusception. An emergency barium enema examination was performed. At the beginning of the examination there was an obstacle to the barium flow (Fig. IA). The cut-off was sharp and the image seen on the television screen suggest-ed a twist of the rectosigmoid. At this point the enema tip was removed and the mass obstructing and intussuscepting was pushed up digitally. The barium enema examination was continued and the barium passed through a narrow lumen of approximately 20 cm. of length in order to reach the normal colon (Fig. i, B, C and D). The lumen measured only a few millimeters and was uneven in width, but the mucosa was smooth and sharp. An extramucosal intramural mass was thus outlined (Fig. 2). At no time did barium pass through the mucosa. An exploratory laparot-omy was performed shortly thereafter. The abdominal cavity was filled with I,2oo-I,5oo cc. of dark blood, some of which was clotted. A large firm mass was felt in the pelvis. The old dark blood was coming from this area. When the sigmoid was reached, it- became obvious that- for a distance of 20 cm. the sigmoid was swollen, dark and tense, and it- exhibit-ed a long rupture of one tenia. The mucosa was intact. The tear was repaired and a diverting colostomy was performed. Twelve days later the patient developed a complete small bowel obstruction. A second laparot-omy showed adhesions of a loop of ileum to the mesentery of the upper sigmoid. The repaired sigmoid tenia had broken open, * From the Departments of Radiology and Surgery, Passavant Memorial Hospital and Northwestern University Medical School, Chicago, Illinois. 170

2 VOL. 107, No. i Intramural Hematoma of the Sigmoid 171 TABLE I PUBLISHED CASES OF INTRAMURAL HEMATOMA OF THE COLON Clinical Barium Case Year Age Sex Site Etiology Manifestation Enema Treatment Exami nation I yr. M Sigmoid Injury during Intestinal No Evacuation local anesthesia obstruction for hernioplasty yr. M Cecum Struck in abdo- Vomiting, ab- No Resection men by handle of dominal pain, bicycle distention yr. 1 Cecum Lifting heavy Pain, vomit- No Evacuation potted plants ing, mass right lower abdomen yr. NI Hepatic Blow toabdomen Mass right Normal Resection flexure by wooden shoe lower yr. M Ascending Struck in the Mass right F illing defect Resection colon abdomen lower in ascending abdomen abdomen mo. li Rectosig- Needle puncture Intestinal No Autopsy moid during treatment obstruction with intraperitoneal fluids yr. M Descending Struck in abdo- Pain, consti- Constricting Resection colon men by a log pation and lesion descendprogressive ing colon distention yr. M Sigmoid Kicked by cow Abdominal No Resection and horse pain and vomiting yr. F Transverse Aftereating Distention, No Resection colon heavy meal vomiting, vague abdominal mass II yr. M Cecum Blow to abdomen Abdominal No Resection in automobile ac- pain cident 12* yr. M Sigmoid No trauma. Abdominal Intramural Evacuation Hypertension? pain and nau- lesion of sig- Obesity? sea. Rectal moid mass. Intussusception colon yr. M Ascending Fell 6 months Diarrhea for Constricting Resection colon prior 3 months deformity ascending colon * This communication.

3 172 Leonid Calenoff and Franklin Lounsbury SEPTEMBER, G. 1. Spot roentgenograms taken during the barium enema examination. (il) Sudden obstruction to the barium flow. (B) After the intussuscepting mass is pushed up digitally, the examination is continued. An extensive extramucosal defect of the sigmoid is outlined. (C) There is a twisting-like effect at both ends of the lesion. The mucosa is smooth and intact and (D) there is spacing between the rectosigmoid and the sacru m. tfl(l there was also a perforation of the mucosa. The sigmoid mass was definitely smaller. There was nothing to suggest malignancy. A biopsy showed chronic inflammatory changes but no tumor. It was OW clear that- a large submucosal intramural hematoma had emptied by rupture of the serosa and muscularis. The residual intramural blood was diffusely infiltrated into the muscularis and could not be resect-ed. l hree months litter, proctoscopic examinatiofl showed edema, scarring and a slight stenosis of the sigmoid. A few small adenomatous polyps were seen. A barium enema examination (Fig. 3) showed spasm of the sigmoid, but a normal mucosa and a normal lumen. A week later the colostomy was closed. In the 6 months since the colostomy the patient- has had no symptoms.

4 \OL. 107, No. Intramural Hematoma of the Sigmoid 73 DISCUSSION The presented twelfth case of intramural hematoma of the sigmoid occurred without an obvious or admitted trauma. Judging from the patient s symptoms, it must have taken about a mont-h for the hematoma to attain its ultimate large size (wit-h most- of the bleeding occurring in the hours prior to surgery) and thus cause an mt-ussusception. It is difficult to establish what caused the initial rupture of the muscularis and serosa. A brief review of all published cases of intramural hematoma of the colon (Table i) illustrates the variety in clinical symptomatology, the various etiologic factors and the outcome of the lesion. Trauma to the abdomen appears to be the leading etiologic factor. No major and constant clinical finding can be found, but abdominal pain and a lower abdominal mass seem to appear often. Barium enema examination was used 11G. 2. Anteroposterior roentgenogram taken after completion of the fluoroscopic examination. The width and the intramural character of the extramucosal lesion are well seen. The intramural hematoma is the soft tissue density to the right of the narrow lumen filled with barium. a FIG. 3. Barium enema examination done 3 months after the first examination, shows a normal mucosa, no mass and a I)atent lumen. Shortly after this examination, the colostomy seen in the right upper abdomen was closed. only times as a diagnostic means. In i case the study was reported normal; twice a constricting nondescript lesion was demonstrated by the barium. In our case a more posi tive roen tgenographi c result was obtained. After reduction of the initial intussusception, a definite intramural mass was demonstrated. \Vhat are the roentgen characteristics of an intramural hematoma of the sigmoid? The involved segment is long, there is a twisting pattern at both ends and the mucosa is identified as being compressed, effaced, but very (lefinitelv smooth and intact. The intramural mass does not have to have an uniform thickness throughout-. The obstruction is not complete. Once the submucosal intramural pat-tern is established, a few benign and rare intramural tumors have to be considered and ruled out: e.g., lipoma, fibroma, enterogenous cyst, granular cell myoblastoma, endothelioma and lymphangioma.2 These tumors are usually more localized and more uniform in shape.

5 174 Leonid Calenoff and Franklin Lounsbury SEPTEMBER, 1969 Anatomically, the involved colon shows a bluish-colored swelling of varying length and is sharply demarcated from the normal bowel. There may be tears in the serosa with blood in the perit-oneal cavity.5 The hemat-oma is more often found between the muscularis and the submucosa, since mostof the vessels are in this area. The treatment of choice is evacuation, but- resect-ion of the involved colon has never been fat-al. SUMMARY A rare case of an intramural hematoma of the sigmoid complicated by intussusception is present-ed. The entire series of i 2. reported cases is briefly reviewed. The etiology, clinical manifest-at-ions and, particularly, the roentgen findings are discussed. L. Calenoff, M.D. Department of Radiology Passavant Memorial Hospital 303 East Superior Street Chicago, Illinois REFERENCES I. HESS, R. A. Intramural hematoma of transverse colon with obstruction and possible impending gangrene: report of case associated with acute hemorrhagic cholecystitis. Am. Surgeon, 1964, 30, MARGULIS, A. R., and BURHENNE, H. J. Alimentary Tract Roentgenology. C. V. Mosby Cornpany, St. Louis, 1967, pp NANCE, F. C., and CROWDER, V. H. Intramural hematoma of colon following blunt trauma to abdomen. Am. Surgeon, 1968,34, SPENCER, R., BATEMAN, J. D., and HORN, P. L. Intramural hematorna of intestine, rare cause of intestinal obstruction : review of literature and, report of case. Surgery, 1958, ti, VAN DE STADT, F. R. Intramural hematorna of colon as cause of severe intraperitoneal hemorrhage. Arc/i. c/iir. neerl., 1962, 14, I I 8-: 22.

6 This article has been cited by: 1. Rebecca M. Rentea, Charles H. Fehring Rectal colonic mural hematoma following enema for constipation while on therapeutic anticoagulation. Journal of Surgical Case Reports 2017:1, rjx001. [Crossref] 2. KiWook Kwon, Dae Young Cheung, Yoon Seo, Shin Bum Kim, Kang Nam Bae, Hyun Jin Kim, Jin Il Kim, Soo-Heon Park, Jae Kwang Kim Supportive Management Resolved a Colonic Intramural Hematoma in an Anticoagulant User. Internal Medicine 53:14, [Crossref] 3. Tsukasa Nozu Idiopathic spontaneous intramural hematoma of the colon: a case report and review of the literature. Clinical Journal of Gastroenterology 2:3, [Crossref] 4. Manoochehr Karjoo, Joseph Domachowske, Stuart Trust Intramuiral Hematoma of the Descending Colon After Blunt Abdominal Trauma. Clinical Pediatrics 39:6, [Crossref]