Giant rectal intramural hematoma following endoscopic submucosal dissection successfully treated with conservative therapy: A case report

Abstract

BACKGROUND

Endoscopic submucosal dissection (ESD) is a viable therapeutic approach for laterally spreading tumors; however, delayed intramural hematoma remains a rare but serious complication. This report describes a successfully managed case, adding valuable evidence to the existing literature. This study demonstrates that conservative management can be both safe and effective, despite previous reports of fatal outcomes. This experience underscores the importance of early recognition and appropriate management of this complication by endoscopists.

CASE SUMMARY

A 60-year-old male underwent ESD due to a rectal laterally spreading tumor. The procedure was completed successfully, and the initial postoperative course was uneventful. On postoperative day 4, the patient developed hematochezia accompanied by a drop in hemoglobin level. Emergency colonoscopy revealed a large intramural hematoma at the ESD site. The patient was treated with conservative therapy including bowel rest, bed rest, antibiotics, and hemostatic agents. The following day, the patient developed abdominal distension and constipation, which were managed conservatively. His condition stabilized, and hemoglobin levels remained stable. By postoperative day 15, symptoms had fully resolved. Follow-up colonoscopy showed near-complete hematoma resolution, and the patient was discharged. Six months later, a well-healed ESD scar confirmed a successful long-term outcome.

CONCLUSION

Delayed intramural hematoma following ESD can be effectively managed with conservative therapy, resulting in complete recovery.

Key Words: Rectal laterally spreading tumor; Endoscopic submucosal dissection; Hematoma; Conservative management; Case report

Core Tip: This report describes a case of delayed intramural hematoma occurring on the fourth day after endoscopic submucosal dissection of a rectal laterally spreading tumor. The intramural hematoma was successfully treated non-surgically, resulting in complete recovery. In contrast to previously reported fatal outcomes, this case provides valuable clinical evidence that careful non-surgical management can achieve excellent results, highlighting an important strategy for endoscopists to avoid unnecessary invasive interventions.

INTRODUCTION

Laterally spreading tumors (LSTs) of the colorectum constitute a unique group of superficial mucosal lesions. Endoscopic submucosal dissection (ESD) for LSTs has demonstrated high rates of en bloc and complete resection (89.8% and 81.9%, respectively), confirming its efficacy and safety as a treatment modality[1]. Common complications linked to ESD include bleeding and perforation, whereas delayed hematoma occurs infrequently. Tanaka et al[2] reported a fatal case of intramural hematoma that developed four days after the procedure. Such postoperative hematomas can lead to serious outcomes, and endoscopists should remain vigilant regarding this potential complication. This report adds novel evidence by documenting a rare but completely resolved case of a large intramural hematoma after rectal ESD managed conservatively, offering practical reference for non-surgical decision-making in similar scenarios.

CASE PRESENTATION

Chief complaints

A 60-year-old man developed hematochezia following ESD, and diagnosed with a large intramural hematoma four days later.

History of present illness

The patient underwent standard colonoscopy which revealed a granular nodular mixed-type LST measuring 2.5 cm × 2.5 cm in the rectum, approximately 15 cm from the anal verge. After careful bowel preparation, ESD was performed (Figure 1). Histopathological analysis of the excised tissue verified the presence of a tubular adenoma. The initial postoperative course was uneventful, with no abdominal pain or hematochezia, and the patient was allowed a liquid diet. On postoperative day 4, the patient developed hematochezia, passing approximately 300 mL of bright red blood in two separate episodes. On the fifth day following ESD, he developed abdominal bloating and difficulty with bowel movements.

Figure 1 Endoscopic views during endoscopic submucosal dissection. A: Preoperative lesion; B: Post-endoscopic submucosal dissection mucosal defect; C: Resected specimen.

History of past illness

The patient denied any significant past medical history.

Personal and family history

The patient did not report any notable personal or family history.

Physical examination

Upon admission, abdominal examination showed slight tenderness without rebound tenderness.

Laboratory examinations

Preoperatively, the patient exhibited normal complete blood count, coagulation profile, liver function, and renal function results. Dynamic monitoring of clinical parameters and symptom progression throughout the hematoma treatment period are shown in Table 1.

Table 1 Dynamic clinical parameters and symptom progression during conservative management.

Postoperative day	Main symptoms	Blood pressure (mmHg)	WBC (× 109/L; reference range: 3.50-9.50)	Hemoglobin (g/L; reference range: 130-175)	Urea (mmol/L; reference range: 3.6-9.5)	Creatinine (μmol/L; reference range: 57-111)	Liver function tests
Day 4	Hematochezia	102/58	14.02	121	9.0	137	Normal
Day 5	Abdominal distension and constipation	108/65	9.81	98	8.9	121	Normal
Day 6	No significant improvement	110/74	6.46	88	8.6	85	-
Day 7	Abdominal distension relieved	105/76	5.77	86	-	-	-
Day 8	No abdominal distension or constipation	115/80	5.5	92	6.9	68	Normal
Day 11	Recovering well	109/67	5.8	112	-	-	-
Day 15	Tolerating liquid diet well	112/78	5.96	115	3.6	63	Normal

“-” unmeasured data at that time point. WBC: White blood cell.

Imaging examinations

On postoperative day 4, the onset of hematochezia prompted an emergent computed tomography scan, which revealed intestinal obstruction (Figure 2A), rectal hematoma and hemoperitoneum (Figure 2B). Emergency colonoscopy revealed a large, purple-walled hematoma at the ESD site, almost completely occluding the lumen and preventing further advancement of the endoscope (Figure 3A).

Figure 2 Computed tomography scan on postoperative day 4. A: Intestinal air-fluid level (white arrow); B: Rectal hematoma (white arrow) and hemoperitoneum (orange arrow).

Figure 3 Colonoscopy. A: Emergency colonoscopy on postoperative day 4 showing a huge intramural hematoma at the endoscopic submucosal dissection site; B: Follow-up colonoscopy on postoperative day 15 demonstrating significant resolution of the hematoma; C: Complete healing with scar formation at the endoscopic submucosal dissection site, confirmed at 6-month follow-up.

FINAL DIAGNOSIS

The patient was diagnosed with a delayed post-ESD intramural hematoma secondary to the ESD procedure.

TREATMENT

Immediate conservative management was initiated, including fasting, bed rest, intravenous antibiotic therapy with cefminox (2.0 g every 12 hours), and intramuscular administration of the hemostatic agent hemocoagulase atrox (2.0 KU every 12 hours).

OUTCOME AND FOLLOW-UP

By postoperative day 15, the patient’s symptoms had improved significantly. Follow-up colonoscopy demonstrated marked resolution of the hematoma (Figure 3B). He was discharged symptom-free on postoperative day 18. During the 6-month follow-up, the patient was asymptomatic, and colonoscopy showed a well-healed scar at the site of resection (Figure 3C).

DISCUSSION

Intramural colorectal hematoma is a rare clinical entity. Reported etiologies in the literature include abdominal trauma[3], anticoagulant use[4], and hematologic disorders[5]. With advancements in endoscopic techniques, cases have also been reported following routine colonoscopy[6] and polypectomy[7]. These endoscopy-related occurrences are often associated with factors such as operator experience, excessive instrument manipulation, or intestinal traction. The clinical presentation of colonic hematoma is typically non-specific, manifesting as abdominal pain, bloating, or hematochezia. In advanced cases, deterioration can result in intra-abdominal infection, peritonitis, perforation, or hemorrhagic shock. Timely and appropriate intervention is critical in order to prevent serious complications. In many cases, individualized conservative management can be effective and helps avoid iatrogenic adverse events that may result from unnecessary or overly aggressive treatment.

Delayed post-ESD bleeding, reported to occur in approximately 2.9% of procedures, is associated with several well-established risk factors, including large lesions (≥ 3 cm), a history of antiplatelet medication use, and tumor location within the rectosigmoid region[8]. In the present case, electrocoagulation was applied to visible vessel stumps during dissection, and no intraoperative bleeding was observed. However, the patient developed postoperative hematochezia, which resolved with supportive care and advice to avoid physical exertion. Notably, the patient’s coagulation profile was normal, and he was not receiving anticoagulation therapy. The lesion in this case did not exhibit any of the previously identified risk factors. The postoperative bleeding was therefore considered to be related to inadequate management of a vascular stump, resulting in delayed hemorrhage. Intraoperatively, all visible vessels at the resection site that were considered potential sources of bleeding were treated with prophylactic electrocautery. It was confirmed that all active bleeding had ceased before terminating the procedure. Therefore, we hypothesize that the source of bleeding originated from a vessel within the deeper submucosal layer. A potential mechanism involves temporary hemostasis achieved by intraoperative electrocoagulation, followed by retraction of the vessel stump. This may have obscured the bleeding site from the endoscopic field, allowing concealed hemorrhage into the loose submucosal space, which subsequently developed into a hematoma. Further hemostasis likely occurred due to increased intraluminal pressure and the compliant nature of submucosal tissue, leading to encapsulation of residual blood and hematoma formation.

Following hematoma formation, the large intramural hematoma obstructed the intestinal lumen, resulting in abdominal distension and cessation of flatus, clinical manifestations consistent with intestinal obstruction. Given the patient’s stable condition, absence of peritonitis, and lack of anticoagulant use that could increase bleeding risk, conservative management was selected. The patient remained on bed rest with limited fluid intake and received intravenous fluids, in addition to intravenous antibiotics to prevent infection and intramuscular hemostatic treatment. Using this approach, the hematoma progressively decreased in size and eventually resolved completely. Hematoma is an uncommon complication of endoscopic procedures, and large-scale clinical data on its management remain limited. Previous reports have described successful supportive therapy of hematomas occurring after cold snare polypectomy of the colon[7]. Other therapeutic strategies have also been explored. Endoscopic purse-string reefing involves deploying an endoloop around the base of the hematoma; once the attached clips are secured to the colonic wall, the loop is gradually tightened to strangulate the lesion[9]. In cases where hematoma formation is accompanied by active bleeding, arterial embolization may be considered. Prompt surgical intervention is warranted when complications such as intestinal perforation occur[10].

This report describes a rare case of intramucosal hematoma following ESD that was successfully managed with conservative therapy, offering valuable clinical insights. To reduce the likelihood of injury to deep vessels and hematoma development, the intraoperative technique should emphasize avoiding excessive electrocoagulation and repeated dissection within the same deep tissue plane. In addition, meticulous hemostasis is essential to prevent blood loss from obscuring the resection bed, an especially critical consideration for large lesions or those with submucosal invasion, where inadequate visualization may compromise the assessment of vascular stump integrity. If a postoperative hematoma develops, conservative management can serve as a safe and effective treatment strategy following careful clinical evaluation.

ESD is primarily indicated for colorectal lesions with submucosal invasion or for large lesions, particularly those ≥ 2 cm[11]. With its increasing clinical adoption, postoperative complications have drawn increasing attention. Current evidence indicates a perforation rate of approximately 5.5%, a bleeding rate of about 4.1%, and surgical intervention required in roughly 1.8% of cases[12]. However, postoperative intramural hematoma is rarely reported and is yet to be well characterized. We identified five published cases (Table 2), of which only two received conservative treatment, both patients were receiving anticoagulation. One patient[2] resumed anticoagulants on postoperative day 1 for atrial fibrillation, deteriorated into diffuse peritonitis, and ultimately died - conservative therapy was chosen against medical recommendation. The other patient[7], who discontinued aspirin perioperatively, remained stable and achieved hematoma resolution within approximately 16 days. In contrast, our patient had no antithrombotic exposure, similar to the three cases[6,9,10] managed non-conservatively, suggesting hematoma formation was unrelated to medication and more likely due to procedural vascular injury or incidental submucosal trauma.

Table 2 Reported cases of intramural hematoma following gastrointestinal endoscopic procedures.

Ref.	Complication	Year	Age (years)	Sex	Anticoagulant therapy	Lesion size (mm)	Device	Time to hematoma onset	Treatment	Outcome
[2]	Hematoma	2023	82	Male	Yes	25	ESD	Postoperative day 4	Conservative treatments	Died on postoperative day 25
[6]	Hematoma	2022	50	Female	No	No available	Colonoscopy	Three hours	Surgery	Discharged
[7]	Hematoma	2023	81	Female	Yes	7	Cold snare polypectomy	Following day	Conservative treatments	Discharged 20 days after admission
[9]	Hematoma	2022	61	Female	No	8	Cold snare polypectomy	Following day	Endoscopic intervention	Hematoma absorption 3 days after intervention
[10]	Hematoma + perforation	2025	43	Female	No	3	Cold snare polypectomy	Two hours	Surgery	Discharged on postoperative day 14

ESD: Endoscopic submucosal dissection.

The success of conservative therapy in the present case hinged on the following favorable factors: Good general condition, stable hemodynamics, absence of peritoneal signs, no radiologic evidence of perforation, and incomplete luminal obstruction without active bleeding. Due to these criteria, conservative management was considered safe and rational. Continuous surveillance was maintained throughout hospitalization, including serial hemoglobin measurements, symptom-focused clinical assessment (pain, bleeding, obstruction), and repeated imaging to monitor hematoma evolution. No progression of hemorrhage or obstruction occurred, culminating in an uneventful recovery.

CONCLUSION

For post-ESD hematoma, conservative management may be considered the first-line approach in patients who are hemodynamically stable, without perforation or diffuse peritonitis, with limited hematoma extent, and when multidisciplinary monitoring and intervention are available. Conversely, endoscopic or surgical intervention should be promptly undertaken if perforation, worsening infection, progressive hematoma enlargement, or persistent active bleeding occurs.