Rectal Ulcer: Can it be a Cause of Massive Lower GI Bleeding?

Abstract

Purpose: A 43-year-old African American male with history of multiple myeloma undergoing chemotherapy presented with severe constipation and acute onset of painless bright red blood per rectum. He denied other GI symptoms. On presentation, his vital signs were normal. Lab work revealed a Hgb 6.6 gm/dl (baseline 7.7 mg/dl, anemic secondary to multiple myeloma), WBC 4.8/cmm, platelet count 100/cmm, MCV 85.2FL, creatinine 1.8 mg/dl, blood urea nitrogen 27 mg/dl, normal electrolytes, total protein 11.2 g/dl, and normal LFTs (except albumin 2.0 g/dl). NG aspiration and lavage were negative for an upper GI source of bleeding. CT abdomen and pelvis was unrevealing except for colonic stool. While preparing for emergent colonoscopy patient had continuous episodes of rectal bleeding with no change in Hgb despite fluid and blood product resuscitation. A digital rectal exam revealed bright red blood on the glove. During colonoscopy, within 10 cm from anal verge, three distinct ulcers were seen with active pulsatile bleeding. An attempt was made to control the bleeding using cautery, hemoclips and epinephrine injection. Hemostasis was achieved on two of these three ulcers and the third was difficult to control despite three modalities of interventions. A decision was made to send the patient for emergent angiography which revealed brisk intermittent extravasation in the distal branches of right inferior rectal artery. Coil and Gel foam embolization was performed with successful hemostasis. Patient received a total of 17 units of pRBC, 2 units of platelets and 4 units of fresh frozen plasma. Patient developed respiratory distress and requiring less than 24 hours of mechanical ventilation. Discussion: Bleeding secondary to rectal ulcer is common but massive hemorrhage requiring massive transfusions is uncommon. In this patient, hemorrhagic rectal ulcers were thought to be due to constipation from narcotic pain medication or in fact a hemorrhagic solitary rectal ulcer syndrome. Major GI bleeding from arterial source is at times difficult to control with endoscopic intervention despite multiple modalities and may require angiographic embolization to achieve hemostasis as in this case. Few case series were published to date emphasizing prompt recognition and early treatment.Figure: No Caption available.