Pseudoaneurysm rupture causing hemoperitoneum following rectal impalement injury: A case report

• Published in: International journal of surgery case reports 2019-01, Vol.55, p.28-31
• Main Author: Choi, Pyong Wha
• Format: Article
• Language: English
• Subjects: Hemoperitoneum; Impalement injury; Pseudoaneurysm; Rectum
• ISSN: 2210-2612; 2210-2612
• DOI: 10.1016/j.ijscr.2019.01.002

•Rectal impalement injury may cause perirectal vascular injury.•Pseudoaneurysm formation by rectal impalement injury is rare.•Pseudoaneurysm rupture of the mid-rectal artery followed by massive hemoperitoneum after rectal impalement injury is extremely rare.•Preoperative radiologic evaluation is crucial for definite surgical management.•When surgery such as involved organ resection is indicated, pseudoaneurysm, which is bleeding focus, should be included in the surgical specimen. Although vascular anatomy of the rectum is complex, pseudoaneurysm followed by massive hemoperitoneum after rectal impalement injury is extremely rare. A 43-year-old man presented with abdominal distension. One day earlier, he had undergone sigmoid loop colostomy for rectal implement injury at a local hospital. After the operation, he had become hemodynamically unstable. Digital rectal examination showed a penny-sized anterior rectal wall defect 6 cm from the anal verge. Computed tomography (CT) revealed a hematoma (12 × 10 × 15 cm) with bleeding in the pelvic cavity and an adjacent pseudoaneurysm in the rectum. A large amount of blood and massive hematoma were evacuated by surgery. The Hartmann procedure was performed, but the pseudoaneurysm was not resected. On the 11th postoperative day, hemoglobin decreased (11.6 g/dL–7.9 g/dL), and CT revealed a recurrent hematoma (6.0 × 4.2 cm) in the pelvic cavity, with a residual pseudoaneurysm. Angiography failed to localize the pseudoaneurysm. Consequently, prophylactic embolization at the anterior branch of both the internal iliac arteries was performed. The subsequent hospitalization course was uneventful. Rectal impalement injury may result in pseudoaneurysm of the rectal arteries. However, pseudoaneurysm rupture of the mid rectal artery, followed by massive hemoperitoneum, has not been reported in the English literature. From our experience, preoperative diagnosis of a pseudoaneurysm is crucial for definite surgical management. When surgical resection is indicated, it should include the underlying pseudoaneurysm. Although pseudoaneurysm rupture causing hemoperitoneum after a rectal impalement injury is extremely rare, meticulous preoperative evaluation is necessary for correct management.