Massive Hematochezia Following Blunt Trauma in a Patient with Crohn's Disease: Intraluminal Bleeding without Hemoperitoneum.

To the Editor: A 29-year-old woman arrived via ambulance to the emergency department with hematochezia 1 h after sustaining blunt abdominal trauma as a passenger in a traffic accident. The patient also had Crohn's disease (CD) and, on arrival, complained of abdominal pain and ongoing hematochezia. On physical examination, she was pale and distressed with a systolic blood pressure of 90 mmHg and a heart rate of 126 beats/min. Routine blood tests showed a hemoglobin level of 86 g/L. Her systolic blood pressure initially responded to a 1.0-L intravenous crystalloid challenge but dropped to 70 mmHg within 30 min, coinciding with further large, bright red per rectal blood loss. Hematochezia also increased (likely fresh blood), and hemoglobin levels dropped to 68 g/L. The patient underwent abdominal computed tomography (CT) with intravenous contrast medium injection. The CT scan showed a suspicious wall defect in the transverse colon as well as free air densities and pericolic fat infiltration [Figure 1a]. Moreover, the presence of active bleeding and increased mucosal enhancement in the transverse colon were notable [Figure 1b]. Diffuse wall thickening and stricture of the terminal ileum, as well as mild wall thickening of the entire colon, were present (typical features of CD). Therefore, the patient was referred to the surgery department and underwent a laparoscopic total colectomy with a diverting ileostomy. On postsurgery, recovery was good, and the patient was discharged to home 30 days later.

Figure 1

(a) A computed tomography scan shows a suspicious wall defect at the transverse colon as well as free air densities and pericolic fat infiltration. Arrow indicates free air. (b) An axial computed tomography scan shows the presence of active bleeding of the transverse colon with increased mucosal enhancement. Arrow indicates active bleeding site.

Acute gastrointestinal hemorrhage is a rare presentation of CD.[1] CD alters endothelial and vascular function that, in turn, contributes to uncontrolled vascular-dependent intestinal damage.[2] CD has been associated with hemoperitoneum since 1970, however, to date, there is no standard protocol regarding treatment in the rare event of massive hemorrhagic CD.[34] Massive gastrointestinal hemorrhage associated with CD was first reported by and subsequently by who described seven patients with CD, who presented with acute life-threatening hemorrhaging. Hematochezia associated with diarrhea is relatively common in CD, however, occasionally, there are patients with more severe bleeding that constitutes the major presenting complaint. Traumatic small bowel perforations in patients with CD have previously been described in literature, with longitudinal ulcers on the mesenteric border being the preferred site; however, the instance of intraluminal hemorrhage with colon perforation reported in this article is the first reported case.[5]

Our patient had hemodynamic instability prompting a provisional diagnosis of intestinal injury with massive hemorrhaging and resulting in an emergency laparotomy. Both medical and surgical options can be considered to manage lower gastrointestinal hemorrhaging due to CD. Conservative approaches have been advocated due to the likelihood of spontaneous cessation of bleeding. A conservative, medical approach is suggested for initial treatment; however, if medical treatment fails or bleeding continues, bowel resection via surgery should be performed.[5] The CT findings (active bleeding in the transverse colon) and blood examination results (rapid anemia due to massive hemorrhaging) prompted the decision for an emergency laparotomy.

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