Flexible Sigmoidoscopy in the Primary Management of Acute Anorectal Bleeding Vessels

Abstract

Acute anorectal bleeding vessels are an important cause of severe haematochezia in elderly, critically-ill patients. These lesions are challenging to manage, and the optimal method for haemostasis remains to be established. We report a case series of 4 such patients who presented to our centre over a 1-year period. All received successful endoscopic haemostasis via sigmoidoscopy. All 4 patients were above the age of 65 (median 76 years) with significant co-morbidities (Table 1). All were critically-ill and required admission to the Intensive Care Unit (ICU) or High-Dependency Unit (HDU). All presented with massive haematochezia during their ICU/HDU stay (median 11 days into admission) with significant blood transfusion requirements (mean 5.8 pints). None had thrombocytopenia or coagulopathy. 1 patient was on Clopidogrel for ischemic heart disease. Computed tomography angio graphy (CTA) was chosen as the index modality of evaluation in 3 patients. In all 3 patients, active arterial haemorrhage in the distal rectum was demonstrated, but embolization was not possible either because lesions were too distal or no culprit vessel was identified. All 4 patients eventually required endoscopic therapy (Table 2). Interventions comprised of adrenaline injection, thermo-coagulation and clips (Figure 1). 2 patients required repeat sigmoidoscopy for definitive haemostasis due to persistent oozing from existing clip sites (mean time to re-bleed 5 days). Endoscopic visualisation was improved with the use of a cap. In critically-ill patients with significant co-morbidities and/or advanced age, CTA is often the first choice in attempting haemostasis via angioembolization. Clinicians often hesitate to perform lower gastrointestinal endoscopy due to concerns about cardiopulmonary complications from sedation and inadequate bowel preparation. Often, however, anorectal bleeding vessels are unamenable to embolisation, and interventional radiology support may not be readily available. CTA with intravenous contrast also entails nephrotoxicity risk, which may be significant in patients with critical illness and systemic inflammatory response syndrome (SIRS) with potential multi-organ dysfunction. Proceeding directly to un-prepped flexible sigmoidoscopy may achieve definitive haemostasis more expediently, with reduction in transfusion requirements, morbidity and even mortality in this patient population. Cap-assisted endoscopy can improve visualisation and help with haemostasis.Figure: Endoscopic clipping of an anorectal bleeding vessel (Patient D).Table: Table. Patient CharacteristicsTable: Table. Interventions and Outcomes