Choichi Sugawa, MD, PhD, Mark Diebel, MD, Jennifer McLeod, MD, Andrew Hollenbeck, MD, Charles E Lucas, MD. Dept. of Surg. Wayne State University
INTRODUCTION: Acute hemorrhagic rectal ulcer (AHRU) is characterized by a sudden onset of painless and massive lower rectal bleeding in elderly, bedridden patients (pts) with major co-morbidities. AHRU, often reported in Japan and East Asia, is not reported in the West. This study examines the incidence, co-morbidities, endoscopic findings, management and outcomes in pts with AHRU.
METHODS AND PROCEDUES: The medical records of 2,253 consecutive inpatients, who underwent colonoscopies on the surgical service at an urban emergency hospital between July 1, 2009 and December 31, 2015, were reviewed.
RESULTS: There were 66 pts (2.9%) out of 2253 inpatients who underwent colonoscopy and were found to have rectal ulcers. Etiologies included stercoral (18 pts), enema-related (17 pts), AHRU (11 pts), solitary (7 pts), HIV related (3 pts), rectal injuries by gunshot wound (3 pts), cocaine induced (2 pts), ischemic (2 pts), pseudomonas (1 pt), idiopathic (1 pt), and non-bleeding acute rectal ulcer (1pt). Patients with colitis, inflammatory bowel disease, pouchitis, and radiation proctitis were excluded. Some stercoral ulcers were difficult to differentiate from AHRU. All 11 AHRU pts presented with painless hematochezia and had major comorbidities. There were five men and six women, with a mean age of 65 (range 45-88). All were admitted to the ICU. Comorbidities included hypertension (7 pts), end-stage renal disease (6 pts), diabetes mellitus (4 pts), CVA (4 pts) and liver failure (3 pts). Five pts had been treated with anticoagulant or antiplatelet agents. Endoscopic classification of AHRU included: (A) long circumferential ulcer (5 pts), (B) multiple small ulcers near or at dentate line (4 pts), (C) round or irregular ulcers (1 pt), and (D) Dieulafoy-like ulcer (1 pt). All ulcers were located in the distal rectum within 10 cm of the dentate line. Four pts underwent successful colonoscopic hemostasis; 3 pts died from comorbidities; 4 pts stopped bleeding spontaneously.
CONCLUSIONS: AHRU, rarely recognized in the West, occurs in elderly, critically ill, and bedridden pts. Most patients present with sudden, severe, painless, rectal bleeding and are best managed by correction of coagulopathy and by endoscopic hemostasis.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 77573
Program Number: P206
Presentation Session: Poster (Non CME)
Presentation Type: Poster
