ISSN: 2373-6372GHOA

Gastroenterology & Hepatology: Open Access
Case Report
Volume 2 Issue 6 - 2015
Endoscopic Ultrasound –Guided Diagnosis and Drainage of a Large retro-Rectal Hematoma with Unusual Presentation
Ali Choukair1* and Assaad Soweid
Servicio de Cirugía General y Aparato Digestivo, Hospital Torrecárdenas (Almería), Spain
Received: August 28, 2015| Published: October 26, 2015
*Corresponding author: José Jacob Motos Micó, Nº4, ACC A, BL 3, 2ºE 04131, Servicio de Cirugía General y Aparato Digestivo, Hospital Torrecárdenas, El Toyo-Retamar, Almería. Spain, Tel: 633257986; Email:
Citation: Choukair A, Soweid A (2015) Endoscopic Ultrasound –Guided Diagnosis and Drainage of a Large retro-Rectal Hematoma with Unusual Presentation. Gastroenterol Hepatol Open Access 2(6): 00064. DOI: 10.15406/ghoa.2015.02.00064

Abstract

Endoscopic Ultrasonography (EUS) use for both diagnostic and therapeutic purposes has markedly increased over the past few years. Most of this growing number for EUS use was focused on upper gastrointestinal indications, with few recent publications directed to its rectal and perianal use. Therapeutic applications currently include but are not limited to drainage procedures via fine needle aspiration (FNA) aimed at pancreatic pseudocysts, infected gallbladders, abscesses, and hematomas whenever accessible. Pelvic hematoma is an uncommon surgical complication of radical prostatectomy with large ones resulting in urethral anastomotic disruption or a pelvic abscess after becoming infected. We here report a large post-radical-prostatectomy retrorectal-hematoma presenting as constipation and back pain which was successfully diagnosed and treated with transrectal EUS-FNA drainage.

Keywords: Endoscopic Ultrasonography; Fine Needle Aspiration; Hematoma; Therapeutic Endoscopic Technique

Abbreviations

EUS: Endoscopic Ultrasonography; FNA: Fine Needle Aspiration

Introduction

Endoscopic Ultrasonography (EUS) use for both diagnostic and therapeutic purposes has markedly increased over the past few years. Most of this growing number for EUS use was focused on upper gastrointestinal indications, with few recent publications directed to its rectal and perianal use [1,2]. Therapeutic applications currently include but are not limited to drainage procedures via fine needle aspiration (FNA) aimed at pancreatic pseudocysts, infected gallbladders, abscesses, and hematomas whenever accessible [3-10].

Pelvic hematoma is an uncommon surgical complication of radical prostatectomy with large ones resulting in urethral anastomotic disruption or a pelvic abscess after becoming infected [11]. We here report a large post-radical-prostatectomy retrorectal-hematoma presenting as constipation and back pain which was successfully diagnosed and treated with transrectal EUS-FNA drainage.

Case Report

A 77 year old male patient presented to the GI private clinic due to a 3 week history of constipation. Past medical history was positive for type 2 diabetes mellitus and coronary artery disease (patient had PTCA + stent insertion). Patient was maintained on oral hypoglycemics and aspirin. He had undergone a prostatectomy 6 month prior to presentation. The patient reported progressive difficulty to defecate accompanied with urinary frequency as well. Upon further investigation, the patient reported having low back pain for the past several weeks that was radiating to both lower extremities. Due to his back pain, his neurologist ordered an MRI of the back, which showed a large cystic mass in the pelvic cavity, located postero-medially to the left and with thickened walls.

The patient was subsequently referred to the gastroenterology department for evaluation. Physical exam were unremarkable except for a mass in the posterior wall of the rectum on digital rectal exam. CAT scan of the pelvis was done showing a multi-loculated cystic lesion 16 x 9 cm in size in the pre-sacral and in the retro-vesical area (Figure 1).

Figure 1: CT-Scan showing pre-sacral cystic lesion.

Blood studies for complete blood count; prostate specific antigen and hydatid serology were done and turned out negative. Due to the lack of a specific diagnosis, a rectal EUS was scheduled. Rectal EUS showed a large cystic anechoic lesion (Figure 2) located in the retro-rectal area with few septations and debris. After localizing the lesion, an FNA with a 22 gauge needle was done and a dark brownish fluid was aspirated (Figure 3).The fluid was sent for analysis and turned out to be hemorrhagic fluid in nature. At the end of the procedure, a total of 600 ml of hemorrhagic fluid was aspirated resulting in almost total disappearance of the lesion and marked improvement in symptoms and relief of the low back pain.

Figure 2: EUS image showing the tip of the FNA needle inside the cystic mass.
Figure 3: The dark-brownish fluid that was aspirated from the cystic lesion.

Discussion

Peri-rectal hematoma is a known yet rare complication of radical prostatectomy. Symptoms of a post-operative hematoma are usually related to anatomical disruption of the urethral anastomosis or to infection of the hematoma. Chronic constipation and back pain as a result of a large retro-rectal hematoma after a radical prostatectomy has never been reported in the literature.

EUS has been shown to be a safe and effective method in exploring the gastrointestinal tract and nearby structures. It has proven to be the test of choice for accurate imaging of gut wall and surrounding structures and its applications have grown over the years to include fine−needle aspiration of target lesions accessible from the gastrointestinal tract for diagnostic and therapeutic purposes [12,13]. In a large national survey, the risk of perforation with EUS was 0.03% and the risk of death was 0.002% [14]. In a study done by Al-Haddad et al, 15 patients with solid perirectal masses underwent EUS-FNA for diagnostic purposes where diagnosis was made in all of them with no complication rate [15].

The real-time visual ability and maneuverability of EUS has made it a preferred modality of intervention for patients with pelvic collections [5,6,16]. This being said, pelvic hematomas that can develop as a complication of radical prostatectomy can therefore be drained and treated by this approach. Limitations to rectal EUS-FNA treatment of such lesions are mostly anatomical/positional such as a distance that is greater than 20mm from the gastrointestinal lumen or a proximal location that limits the maneuverability and access of the echo endoscope.

To our knowledge this case represents the first reported case where rectal EUS - FNA was performed on a rectal cystic mass for therapeutic intention, and with complete resolution of the symptoms being achieved directly post procedure. This proves that EUS-FNA is a valuable technique for the diagnosis and management of accessible abdominal masses and can eliminate the need for additional studies, surgery, or both which would prove to be cost effective [17].

References

  1. Bhutani MS, Nadella P (2001) Utility of an upper echo endoscope for endoscopic ultrasonography of malignant and benign conditions of the sigmoid/left colon and the rectum. Am J Gastroenterol 96(12): 3318-3322.
  2. Schwartz DA, Wiersema MJ, Dudiak KM, Fletcher JG, Clain JE, et al. (2001) A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn's perianal fistulas. Gastroenterology 121(5): 1064-1072.
  3. Seewald S, Imazu H, Omar S, Groth S, Seitz U, et al. (2005) EUS-guided drainage of hepatic abscess. Gastrointest Endosc 61(3): 495-498.
  4. Seewald S, Brand B, Omar S, Yasuda I, Seitz U, et al. (2004) EUS-guided drainage of subphrenic abscess. Gastrointest Endosc. 59(4): 578-580.
  5. Varadarajulu S, Drelichman ER (2007) EUS-guided drainage of pelvic abscess (with video). Gastrointest Endosc 66(2): 372-376.
  6. Giovannini M, Bories E, Moutardier V, Pesenti C, Guillemin A, et al. (2003) Drainage of deep pelvic abscesses using therapeutic echo endoscopy. Endoscopy 35(6): 511-514.
  7. Varadarajulu S, Drelichman ER (2009) Effectiveness of EUS in drainage of pelvic abscesses in 25 consecutive patients (with video). Gastrointest Endosc 70(6): 1121-1127.
  8. Shami VM, Talreja JP, Mahajan A, Phillips MS, Yeaton P, et al. (2008) EUS-guided drainage of bilomas: a new alternative? Gastrointest Endosc 67(1): 136-140.
  9. Kahaleh M, Wang P, Shami VM, Tokar J, Yeaton P (2005) Drainage of gallbladder fossa fluid collections with endoprosthesis placement under endoscopic ultrasound guidance: a preliminary report of two cases. Endoscopy 37(4): 393-396.
  10. Baron TH, Topazian MD (2007) Endoscopic transduodenal drainage of the gallbladder: implications for endoluminal treatment of gallbladder disease. Gastrointest Endosc 65(4): 735-737.
  11. Shekarriz B, Upadhyay J, Wood DP (2001) Intraoperative, perioperative, and long-term complications of radical prostatectomy. Urol Clin North Am 28(3): 639-653.
  12. Gress FG, Hawes RH, Savides TJ, Ikenberry SO, Lehman GA (1997) Endoscopic ultrasound-guided fine-needle aspiration biopsy using linear array and radial scanning endosonography. Gastrointest Endosc 45(3): 243-250.
  13. Giovannini M, Seitz JF, Monges G, Perrier H, Rabbia I (1995) Fine-needle aspiration cytology guided by endoscopic ultrasonography: results in 141 patients. Endoscopy 27(2): 171-177.
  14. Adler DG, Jacobson BC, Davila RE, Hirota WK, Leighton JA, et al. (2005) ASGE guideline: complications of EUS. Gastrointest Endosc 61(1): 8-12.
  15. Al-Haddad M, Wallace MB, Woodward TA, Gross SA, Hodgens CM, et al. (2008) The safety of fine-needle aspiration guided by endoscopic ultrasound: a prospective study. Endoscopy 40(3): 204-208.
  16. Trevino JM, Drelichman ER, Varadarajulu S (2008) Modified technique for EUS-guided drainage of pelvic abscess (with video). Gastrointest Endosc 68(6): 1215-1219.
  17. Erickson RA, Tretjak Z (2000) Clinical utility of endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration in retroperitoneal neoplasms. Am J Gastroenterol 95(5): 1188-1194.
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