Traumatic Rectal Hematoma With Spontaneous Luminal Drainage

Gastrointestinal hematomas are a rare but potentially fatal complication comprising of 5-10% of patients with acute abdomen. Most spontaneous hematomas occur in the jejunum, duodenum, and ileum. Only 1-5% of cases involve the rectum. Blunt trauma and anticoagulation leading to spontaneous gastrointestinal hematomas have been reported in the literature. However, there are no published incidents to our knowledge that involve anticoagulation and trauma. We report a novel case of a draining rectal hematoma masquerading as a gastrointestinal bleed in a patient with a rectal hematoma on anticoagulant therapy complicated by a recent fall. An 83-year old female with past medical history of atrial fibrillation on warfarin, chronic obstructive pulmonary disease, and hypertension presented with hematochezia and abdominal pain. She had a mechanical fall one week prior. Physical exam was remarkable for bilateral lower quadrants and suprapubic tenderness to palpation. Abdominal computed tomography (CT) showed a 10.7 × 8.6 × 11.9 cm perianal hematoma. Laboratory studies showed international normalized ratio (INR) 10.9, protime 95.1 sec, white blood cell count (WBC) 16.31×103 uL, hemoglobin 6.7 g/dL, hematocrit 20.3, and platelet count of 358 x 103 /uL. She was transfused 1 unit of packed red blood cells and 2 units of fresh frozen plasma. The patient did well for a few days of conservative management. However, she was transferred to the intensive care unit with an acute episode of hematochezia on day 4. Sigmoidoscopy showed an area of submucosal bulging with a large ulcer in the rectum. Two tracts communicating with the hematoma and draining old blood were identified. The patient's blood counts remained stable. She did not require any endoscopic or surgical management. Literature review shows few reported cases on rectal hematomas but none on spontaneous intraluminal drainage. Our case illustrates that conservative management with spontaneous drainage is both safe and effective. Our case also suggests that endoscopic or surgical tract formation for drainage into the lumen may be a safe treatment option as the intraluminal tract functions similarly to percutaneous abscess drainage.Figure 1Figure 2Figure 3