older adults with abdominal pain have a six- to eight - fold increase in mortality compared to younger patients [ 1 , 2 ] . intramural colonic hematomas manifest rarely as complications following blunt traumas or accompanying diseases with bleeding tendency . a 72-year - old male with cerebral palsy was admitted following development of symptomatic pulmonary embolism for the initiation of therapeutic anticoagulation including heparin drip and oral coumadin . prior to initiation of therapeutic anticoagulation , he had a computed tomography ( ct ) scan angiogram of his chest , abdomen and pelvis . a pulmonary embolism and large stool burden were noted on the ct scan and tap water enemas were initiated following the start of the heparin drip and coumadin initiation ( fig . a complete blood count demonstrated an acute drop in hemoglobin from 12 to 6 , partial thromboplastin time 100 and international normalized ratio was 3.5 . the patient was transfused 2 units packed red blood cells , but his hemoglobin did not increase . on exam there was also some new mucoid blood drainage and abdominal tenderness with distension . a repeat ct scan angiogram demonstrated a 15  6  3 cm abdominal intramural hematoma ( fig . given the increasing abdominal pain and concern for perforation as well as lack of response to blood products , an exploratory laparotomy was performed . at laparotomy a 30  15 cm abdominal recto - sigmoid hematoma was discovered distending the previously capacious bowel wall without perforation ( fig . large clamps were used to transect the distal bowel at the recto - sigmoid junction and the area of transection was oversewn . it is likely that dilated colon allowed for a large amount of hematoma to accumulate . the patient recovered post - operatively and was discharged following return of bowel function . following the operation on postoperative day 1 coagulation was resumed without any additional issues . figure 1:ct  abdomen and pelvis with intravenous contrast . admission imaging demonstrating large colonic stool burden in the axial ( a ) , coronal ( b ) and sagittal orientation ( c ) . ct abdomen and pelvis following enema demonstrating large colonic wall hematoma axial ( d ) , coronal ( e ) and sagittal orientation ( f ) . figure 2:intraoperative photograph of the large intramural hematoma of the sigmoid colon descending into the recto - sigmoid junction . admission imaging demonstrating large colonic stool burden in the axial ( a ) , coronal ( b ) and sagittal orientation ( c ) . ct abdomen and pelvis following enema demonstrating large colonic wall hematoma axial ( d ) , coronal ( e ) and sagittal orientation ( f ) . intraoperative photograph of the large intramural hematoma of the sigmoid colon descending into the recto - sigmoid junction . intramural hematomas of the alimentary tract are uncommon , occurring most frequently in the setting of blunt abdominal trauma ( duodenum most common , colon least common ) , and in 1536% are spontaneous in patients with underlying hematologic disease or on anticoagulant therapy . the incidence of all bleeding complications during anticoagulation therapy ranges from 5 of 48% , but gastrointestinal hemorrhage occurs in only 2 to 4% of patients . small bowel hematoma has an incidence of 1 case per 2500 anticoagulated patients per year , while large bowel hematomas have an even lower incidence in the literature . gastrointestinal complications following anticoagulation can present with bleeding into the intestinal lumen , usually related to some underlying mucosal abnormality , retroperitoneal hemorrhage or bleeding into intra - abdominal organs ; less common are intramural hematomas . rectal hematoma and subsequent perforation have been described in patients following enemas and radiographic contrast enemas   due to both instrumentation and hydrostatic pressure . one study demonstrated that the incidence of iatrogenic large bowel perforations ranges from 0.1 to 0.9% following colonoscopy and barium enemas . the differential diagnosis of abdominal pain for a patient on anticoagulation is broad including rectus sheath hematoma , retroperitoneal hematoma , intestinal / mesenteric hematoma , bleeding diverticula and rectal trauma from enema or foreign object . the use of ct as the first imaging modality in the evaluation of patients with acute abdominal complaints especially in the elderly population . ct characteristics of colonic hematoma include circumferential wall thickening , intramural hyper - density , luminal narrowing and intestinal obstruction . additional adjuncts for diagnosis consist of rigid proctoscopy which demonstrate colonic intramural hematomas as round shaped , dark reddish submucosal masses often obstructing the luminal space . for patients with intramural hematomas conservative management includes removing the anticoagulation therapy , correcting coagulopathy , intestinal decompression and avoiding oral intake while awaiting spontaneous resorption of the hematoma . the challenge is to distinguish patients with self - limiting intramural hematoma from those with more severe pathology . conventional physical exam signs are inadequate to distinguish more ill patients as even a simple hematoma may also present with high fevers , leukocytosis and rebound tenderness . if the intramural hematoma causes obstruction or if the cause of the bowel obstruction is unknown , surgical intervention for colonic hematoma is warranted . drainage of the hematoma may increase the risk of serious infection as it introduces bacteria to a previously sterile hematoma . a review of the literature demonstrates a shift in the management of colonic hematomas over the past 50 years . cases prior to 1969 were most commonly treated with surgical intervention . however , following 2010 they were managed more frequently conservatively . treatment of colonic hematomas depends on symptoms and clinical findings [ 11 , 14 ] . overall bowel obstruction in a patient on anticoagulation with acute abdominal pain results in operative exploration in 67% ( 42 of 51 patients ) . for those reasons indications for immediate surgical intervention include active and persistent intra - abdominal bleeding , intestinal wall ischemia with or without bowel perforation and peritonitis . many case series and reports have demonstrated that patients with distal colonic hematomas required diverting colostomies 80% of the time . endoscopic drainage requires colonic wall viability   but could result in relief of the  tamponade effect of the hematoma . selective mesenteric embolization can be performed in patients with an active blush into the colonic wall with an 85% success rate , and an overall 20% of complication as a result of the procedure . recto - sigmoid hematomas should be considered as a diagnosis for a patient with a dropping hemoglobin and abdominal pain in the setting of an enema on therapeutic anticoagulation . if obvious signs of clinical deterioration such as free air and failure to respond to correction of coagulation are identified , then operative intervention should commence . the authors declare that there is no conflict of interests regarding the publication of this paper .