Acute Hemorrhagic Rectal Ulcer (AHRU) Presenting as Massive Lower GI Bleeding in a Hospitalized Critically Ill Patient

Abstract

Purpose: Massive lower GI bleeding is a frequent complication,with potentially catastrophic outcome, in critically ill hospitalized patients. We present a case of massive lower GI bleed due to acute hemorrhagic rectal ulcer (AHRU) treated successfully with endoclipping. Case: A 58-year old African-American male with a history of DM and HTN was admitted to the ICU for a large hemorrhagic stroke. One week later, he developed a painless massive lower GI bleed with precipitous drop in hemoglobin from 14 gm/dl to 8.5 gm/dl. No history of constipation noted in the preceding period. At colonoscopy, he was found to have a large shallow ulcer measuring 1.5 cm × 2 cm just proximal to dentate line, with a central spurting vessel. Bleeding was effectively controlled with an endoclip followed by injection of epinephrine. On subsequent follow up, no further bleeding was noted. Discussion: Massive lower GI bleeding is a common complication among hospitalized patients, and the outcome is based on several criteria including the severity, etiology, patient's underlying co-morbidities, and the efficiency of therapeutic interventions. AHRU is a recently coined entity describing painless massive lower GI bleeding originating from an ulcer in the distal rectum, typically in critically ill patients with multiple comorbidities such as strokes, heart failure, respiratory failure, sepsis, etc. The syndrome was first reported in the Far East, with fewer cases reported recently from other parts of the world. Diagnosis requires careful examination at the time of colonoscopy of the rectum and ano-rectum for mucosal ulceration. AHRU may appear as single or multiple ulcers with circumferential, linear, round, geographical, or Dieulafoy-like lesions located just proximal to the dentate line. Histopathologically, the lesions appear necrotic with denudation of covering epithelium, hemorrhage, and thrombi in the vessels of the mucosa and underlying stroma, mimicking stress-related mucosal injury. While endoscopic therapy is highly effective, re-bleeding is common. As it remains under-recognized in the western hemisphere, we believe that increased awareness of this entity is likely to impact the outcome of massive lower GI bleeding in critically ill hospitalized patients.Figure: (a) Ulcer at dentate line; (b) pulsating.