Massive per rectal bleeding following blunt abdominal trauma: First presentation of Crohn's disease

Abstract

Introduction

Inflammatory bowel disease is a chronic and relatively common disorder with heterogeneous presentation. Peak incidence occurs in the second and third decades of life. We present a patient with Crohn's disease whose first presentation was profuse bleeding/rectum following blunt abdominal trauma.

presentation of case

A 29 year old previously healthy man presented one hour after sustaining relatively mild abdominal trauma, due to fall onto the ball during a rugby match. He complained of abdominal pain and one episode of large fresh rectal bleeding. He was pale and distressed with hypotension, tachycardia and abdominal guarding & fresh blood on digital rectal examination. With a provisional diagnosis of intestinal injury he was taken to theatre. Right hemi-colectomy was done for a thickened and inflamed segment of distal ileum, a large adjacent mesenteric haematoma & mesenteric lymph nodes and blood in distal bowel. Histology confirmed the features of Crohn's disease.

discussion

Crohn's disease is unusual cause of massive lower gastrointestinal bleeding occurring in 0.9–6% of patients. Rectal bleeding associated with diarrhoea is relatively more common than massive bleeding. The presence of Crohn's disease in young patients presenting like this is unlikely to be suspected and diagnosis could only be made after laparotomy.

1. Introduction

Inflammatory bowel disease (IBD) is a chronic and relatively common disorder of uncertain aetiology. Both ulcerative colitis and Crohn's disease are heterogeneous in their presentation, lack internationally uniform diagnostic criteria and can be associated with long delays between symptom onset and definite diagnosis. These characteristics make the identification of the disease difficult. Ulcerative colitis and Crohn's disease may manifest at any age, their peek incidence occurs in the second and third decades of life. We present a patient with Crohn's disease whose first presentation was profuse per rectal bleeding following blunt abdominal trauma.

2. Presentation of case

A previously healthy 29 year old man arrived via ambulance to the emergency department with per rectal bleeding one hour after sustaining relatively mild abdominal trauma, falling onto the ball during a rugby match. On arrival he complained of worsening abdominal pain and had one episode of large blood loss on defecation. On physical examination he was slightly pale and distressed with blood pressure of 90 mmHg systolic and heart rate of 130 beats per minute. Abdominal examination revealed voluntary guarding with scanty bowel sounds. Fresh blood was seen on per rectal examination. His systolic blood pressure initially responded to a 1.5 l intravenous crystalloid challenge, but dropped to 90 mmHg within 15 min, coinciding with further large bright red per rectal blood loss. A provisional diagnosis of intestinal injury causing massive and continued haemorrhage due to blunt abdominal trauma was made and he was taken to theatre for laparotomy with endoscopy available.

At laparotomy a segment of the distal ileum was found to be thickened and inflamed with a large haematoma along the mesenteric border with multiple palpable mesenteric lymph nodes (Figs. 1 and 2). The bowel distal to this was distended with blood. No perforation was identified. The findings were consistent with Crohn's disease with enteric bleeding due to trauma to the inflamed segment. A limited right hemi-colectomy was performed and the specimen sent for histology. Following surgery, he made a good recovery and was discharged home at day 7. He remains well at one year. The histology of the excised specimen confirmed Crohn's disease (Figs. 1 and 2).

Fig. 1.

Arrows showing mesenteric fat encroachment (white), inflamed bowel with stricture (blue) and mesenteric haematoma (black). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.)

Fig. 2.

Arrows showing mesenteric lymphadenopathy (white), haematoma (black), inflamed bowel (blue) and normal looking bowel (yellow). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.)

3. Discussion

Acute gastrointestinal haemorrhage is a rare presentation of Crohn's disease that represents a diagnostic difficulty if not accompanied with other associated symptoms.¹ Gastrointestinal haemorrhage in the setting of inflammatory bowel disease has traditionally been associated with ulcerative colitis. Crohn's disease has been described in text books as an unusual cause of massive lower gastrointestinal bleeding occurring in 0.9–6% of patients.^2–4 Massive gastrointestinal haemorrhage associated with Crohn's disease was first reported by and then by who described seven patients with Crohn's disease who presented with acute life-threatening haemorrhage.⁵ Rectal bleeding associated with diarrhoea is relatively common in Crohn's disease but there are also occasional patients in whom bleeding is more dramatic and constitutes the major presenting complaint.

Traumatic small bowel perforations in patients with Crohn's disease have previously been described in literature with mesenteric border of longitudinal ulcers is a preferential site of perforation in Crohn's disease.^6–8

Our patient had no significant past medical history and this was his first presentation following blunt abdominal trauma. Hemodynamic instability prompted a provisional diagnosis of intestinal injury with massive haemorrhage and the decision for emergency laparotomy.

The management of lower gastrointestinal haemorrhage due to Crohn's disease includes both medical and surgical options. Conservative therapy has been advocated in view of likelihood of spontaneous cessation of bleeding.⁹

But the presence of Crohn's disease in young patients presenting like this with obvious trauma and absence of other symptoms is unlikely to be suspected and diagnosis could only be made after laparotomy.

Conflict of interest statement

No conflicts of interest.

Funding

No funding source.

Consent

Consent obtained, no identifiable details included in study.

Author contribution

Both trainees collected the data and wrote paper, literature review under direct supervision of the trainer who provided full guidance in whole process.

Open Access

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