Sometimes "Wait and See" Policy Is the Best Cure for a Mass Found on Colonoscopy

Introduction: Although most rectal masses are histologically characterized as adenocarcinomas, the rectum can be affected by a wide variety of tumors and tumor-like conditions that can mimic the symptoms caused by rectal adenocarcinoma, including mucosal or submucosal rectal tumors such as lymphoma, gastrointestinal stromal tumor, leiomyosarcoma, neuroendocrine tumor, hematoma and hemangioma. Recognition of the existence of these masses and their key clinical and imaging features is crucial for clinicians to accurately diagnose and appropriately manage these conditions. Case description/methods: An 84-year-old gentleman with a history of coronary artery disease on clopidogrel presents with an acute episode of rectal pain, hematochezia, and urinary retention. His physical examination was remarkable for active bleeding from the rectum. He was placed on a proton pump inhibitor infusion. He underwent an abdominal computed tomography angiography (CTA) showing a rectal mass and intraluminal active vascular extravasation in the left posterolateral rectum. A colonoscopy (A) was performed and was consistent with an infiltrative, sub-mucosal and obstructing 10 cm mass with no evidence of bleeding. Given the CTA findings, patient underwent embolization of the superior rectal artery by interventional radiology. Subsequently, he underwent a lower endoscopic ultrasound (EUS) which showed a hypoechoic and heterogenous mass in the rectum with sonographic evidence suggesting a mass to be originating from the muscularis propria with invasion into the perirectal fat invasion (B). Biopsy of the lesion revealed benign colonic mucosa with patchy ulceration suspected to be a gastrointestinal stromal cell tumor. Patient’s symptoms resolved, and he was discharged in stable condition. A repeat lower EUS (C, D) was performed in a month and showed a complete resolution of previously found mass consistent with a rectal hematoma that has now resolved. Discussion: Intramural hematomas may occur anywhere in the alimentary tract but rarely occur in the rectum. Rectal hematomas are rare but important clinical entities because of their inclination to cause hemorrhage. The etiologies may include abdominal trauma, anticoagulant therapy, or bleeding diathesis such as hemophilia and leukemia. Most patients with intramural hematomas present with signs of intestinal obstruction. Conservative therapy is usually sufficient because the hematomas will undergo spontaneous resorption, but treatment decisions depend on the symptoms and clinical findings.Figure 1.: Colonoscopic and EUS findings of resolving hematoma.