Fernandes Samuel, Gonçalves Ana Rita, Araújo Correia Luís
Gastrenterologia e Hepatologia, Hospital Santa Maria, Portugal.
Serviço de Gastrenterologia e Hepatologia, Hospital Santa Maria, Portugal.
Rev Esp Enferm Dig. 2016 Aug;108(8):501-2.
A 73-year-old man was admitted to our clinic with sudden left quadrant abdominal pain and hematochezia. There was no history of trauma. He denied other symptoms or taking off-the-counter medication. His medical history was relevant for ischemic and aortic-mitral valve disease with prosthetic valves for which he was medicated with aspirin and warfarin. On physical examination the patient presented normal vital signs with tenderness on palpation of the left side of the abdomen. Laboratory tests revealed moderate anemia (10.8 g/dl) and thrombocytopenia (135.000x10^9 U/L) with therapeutic international normalized ratio (2.53). Colonoscopy revealed an extensive area of erythematous and bluish mucosa with an apparent torsion of the proximal descending colon around a volumous hematoma measuring 6.5x3 cm (Figure 1 A-C). Urgent abdominal CT confirmed the presence of a large intramural hematoma of the descending colon (Figure 2 A-B). A conservative approach was adopted with temporary suspension of anticoagulation. Given the high thrombotic risk, abdominal ultrasound was performed after 72 hours showing considerable reduction in the size of the hematoma. Anti-coagulation was then resumed without complications. One month later, colonoscopy was repeated showing complete healing of the mucosa. The increasing use of anti-aggregating and anti-coagulant therapy, especially in elderly patients, explains the increasing incidence of bleeding events seen in this population. However, gastrointestinal hematomas are estimated to occur in only 1 for every 250.000 anti-coagulated patients. Diagnosis is based on characteristic radiologic findings. While most parietal hematomas can be approached conservatively, surgery is indicated in the presence of complications or persistence of the hematoma.
一名73岁男性因突发左下腹疼痛和便血入院。无外伤史。他否认有其他症状或服用非处方药。他有缺血性疾病和带人工瓣膜的主动脉 - 二尖瓣疾病病史，正在服用阿司匹林和华法林。体格检查时，患者生命体征正常，左侧腹部触诊有压痛。实验室检查显示中度贫血（血红蛋白10.8 g/dl）和血小板减少（血小板计数135,000x10^9 U/L），国际标准化比值处于治疗水平（2.53）。结肠镜检查发现广泛的红斑和蓝色黏膜区域，降结肠近端围绕一个6.5×3 cm的巨大血肿明显扭转（图1 A - C）。紧急腹部CT证实降结肠存在巨大壁内血肿（图2 A - B）。采取保守治疗方法，暂时停用抗凝药。鉴于高血栓形成风险，72小时后进行腹部超声检查，显示血肿大小显著减小。然后恢复抗凝治疗，未出现并发症。1个月后，再次进行结肠镜检查，显示黏膜完全愈合。抗聚集和抗凝治疗的使用增加，尤其是在老年患者中，解释了该人群中出血事件发生率的上升。然而，估计每250,000名接受抗凝治疗的患者中仅1例会发生胃肠道血肿。诊断基于特征性的影像学表现。虽然大多数壁内血肿可采用保守治疗，但出现并发症或血肿持续存在时则需手术治疗。
