Management of Severe Rectal Bleeding from Trans-rectal Ultrasound (TRUS) Guided Biopsy

Abstract

Purpose: Rectal bleeding is a known complication from TRUS prostate biopsies; however, it is usually self-limiting. Below we report a case of severe rectal bleeding in a Jehovah's Witness from TRUS of the prostate and management challenges. Case: A 70-year-old Caucasian male, a Jehovah's Witness, with a history of benign prostate hypertrophy (BPH), diabetes mellitus, and coronary artery disease (CAD) on antiplatelet agents presented with rectal bleeding after a TRUS-guided prostate biopsy. He presented to the hospital 3 days after the procedure due to persistent clots per rectum. Physical exam revealed gross blood in stools with benign abdominal exam. He was hemodynamically stable except for borderline low blood pressure (BP). His hemoglobin (Hb) was 13.9 g% with platelet count of 167,000. The international normalized ratio (INR) was one. A CT scan of the abdomen and pelvis was negative. Colonoscopy showed a spurting vessel in the rectum. Endoclips were applied to secure hemostasis. However due to a continuous Hb drop, ano-rectal suturing was done. He was discharged in stable condition after 24 hours. The incidence of rectal bleeding post-TRUS-guided biopsy is low. The ano-rectal area is richly supplied by vascular bed and any injury will lead to brisk bleeding. Usually bleeding is seen immediately after the procedure for which rectal tamponade or endoscopic measures are perfomed, such as injection of sclerosing or vasoconstrictive agents, thermocoagulation, band ligation and endoclips. A review of earlier literature showed no significant change in major complications after a TRUS-guided prostate biopsy despite use of antiplatelet or anticoagulant agents. Previously most complications were management by urologists however recently, the use of endoscopy by gastroenterologists has been increasing. In the above case, no interventions were conducted the patient was asymptomatic post procedure and symptoms were delayed by three days which is rare. Given the complex situation of rectal bleeding status post-TRUS-guided prostate biopsy in the Jehovah's Witness an aggressive approach was required with combined endoclips and surgical suturing which is also rare.Figure: Colonoscopy view of spurting blood vessel (inside rectum) and application of clip.