Spontaneous mesenteric hematoma complicating an exacerbation of Crohn’s disease: report of a case
© Ashrafian et al.; licensee BioMed Central Ltd. 2014
Received: 17 July 2013
Accepted: 27 May 2014
Published: 3 June 2014
Spontaneous mesenteric haematoma is a rare condition that occurs due to localized bleeding in the mesenteric vascular tree of a bowel segment in the absence of an identifiable cause. Here we report a case of spontaneous mesenteric haematoma during an inflammatory exacerbation of Crohn’s disease. The patient underwent surgical management for small bowel obstruction secondary to Crohn’s disease, however the concurrent presence of a spontaneous mesenteric haematoma in the mid-jejunal mesentery was successfully managed conservatively.
This case identifies the first association of spontaneous mesenteric haematoma with an exacerbation of Crohn’s disease and highlights the need to consider rare differential diagnoses such as SMH when performing radiological assessment of unexplained symptoms in inflammatory bowel disease patients.
KeywordsCrohn’s disease Mesenteric haematoma Inflammatory bowel disease Surgery
Spontaneous mesenteric haematoma (SMH) is a rare condition of unknown aetiology. It can be managed conservatively in the event that there is no associated mesenteric haemorrhage. It must be clinically distinguished from spontaneous mesenteric intraperitoneal haemorrhage (or abdominal apoplexy) where there is rupture or bleeding from a specific mesenteric vessel due to an unknown cause that typically requires urgent surgical management due to its high mortality. This report presents the first case in the literature associating SMH with an inflammatory exacerbation of Crohn’s disease.
The surgical complications of Crohn’s disease include bowel obstruction, fistulation, ulceration, anal fissures and cancer . The pathological severity of this condition derives from a combination of inherited factors and environmental triggers that lead to gut inflammation and local microvascular ischaemia [2, 3]. The vascular component of Crohn’s disease has been primarily associated with arterial and venous thrombotic events that can lead to mesenteric ischaemia, venous congestion and bowel perforation [1, 4]. There is an association between patients with Crohn’s disease who suffer from intramural bowel haematomas, bleeding diatheses and anticoagulation therapy . To the best of our knowledge, we report the first case in the literature of spontaneous jejunal mesenteric (mesojejunal) haematoma.
Spontaneous mesenteric haematoma (SMH) is a rare condition that occurs due to localized bleeding in the mesenteric vascular tree of a bowel segment with unknown aetiology [6–8]. It can be clinically distinguished from the related disease pathology of spontaneous mesenteric intraperitoneal haemorrhage (abdominal apoplexy) that occurs due to the spontaneous rupture of a specific mesenteric vessel likely from undiagnosed mesenteric arterial dissection and perivascular pseudo aneurysms. In these cases there is evidence of both intraperitoneal and retroperitoneal haemorrhage . SMH can be managed conservatively [6–8] if there is no associated haemorrhage and although the patient in this case underwent surgery for intestinal stenosis, the concurrent mesenteric haematoma was successfully managed conservatively.
Patients with isolated SMH typically present with non-specific symptoms of generalised abdominal pain and as a result the haematoma is usually identified on imaging modalities such as CT. Although the cause is unknown, the disease process may be associated with unidentified anticoagulation mismanagement or even undiagnosed connective tissue disease [6–8].
Our case demonstrates the presence of localised mid-jejunal mesenteric fat haematoma. Localised visceral inflammation is a recognised contributor to confined microvascular bleeding  so that the inflammatory exacerbation of Crohn’s disease in this case may have resulted in severe mesenteric fat inflammation to initiate localised capillary leakage and subsequent haematoma.
Mesenteric fat has been recently recognised an essential location for the generation of Crohn’s gastrointestinal inflammation [11, 12]. Here bacterial translocation associated with immunoregulation through nucleotide-binding oligomerization domains (NOD1 and 2) and Toll-like receptors (TLRs 2 and 4) result in an increase in local inflammatory mediators including C-reactive-protein (CRP). The powerful inflammatory role of the bowel mesentery might be a contributory factor in the association between Crohn’s exacerbation and mesenteric haematoma in this case.
Our intraoperative findings of mesojejunal haematoma reflect the current underestimation of Crohn’s ileitis, demonstrating explicit involvement of the mesenteric fat with an associated mesenteric haematoma. This case also highlights how mesenteric abnormalities such as SMH may explain refractoriness or recurrence of symptoms despite intensifying steroid therapy. Indeed, it is possible that ileal compression caused by a mesenteric mass such as this may explain many of the symptoms accredited to Crohn’s strictures. As a result, we believe that an increased awareness of the role of the bowel mesentery may give new insights into Crohn’s disease pathogenesis. Furthermore, assessment for mesenteric abnormalities may guide future clinical and radiological assessment of unexplained symptoms in patients suffering form this multi-systemic inflammatory process, and identify rare differential diagnoses such as SMH.
We describe a case of spontaneous mesenteric haematoma in a female patient suffering from an exacerbation of Crohn’s disease and intestinal stenosis. The mesenteric haematoma was identifiable both on pre-operative computerised tomography and intra-operatively. This case identifies the first association of spontaneous mesenteric haematoma with an exacerbation of Crohn’s disease and highlights the need to consider rare differential diagnoses such as SMH when performing radiological assessment of unexplained symptoms in inflammatory bowel disease patients.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Nucleotide-binding oligomerization domain
Spontaneous mesenteric haematoma
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