Complaints Of Rectal Bleeding Research Articles

S2654 Severe Rectal Bleeding due to Foreign Body Ingestion

Introduction: Foreign body ingestion is often seen in children and the elderly. Food particles such as chicken or fish bones are the most often ingested foreign bodies; however, most patients do not recall ingestion. Clinically, most foreign bodies pass through the GI tract without issue, however, complications occur in roughly 1% of cases. Complications of foreign body ingestion include bleeding, bowel obstruction, and perforation. We present a case of a 95-year-old female presenting with bright red blood per rectum found to have foreign body impaction with ulceration in the rectosigmoid region. Case Description/Methods: A 95-year-old female with past medical history of diverticulosis and GERD presented with a complaint of rectal bleeding. She had experienced 7 episodes of voluminous bright red blood per rectum with diffuse crampy abdominal pain. She had no history of previous GI bleeds. Her most recent colonoscopy was 25 years prior with diverticulosis only. DRE was positive for bloody stool and her hemoglobin was 10g/dL with a baseline of approximately 13. CT scan showed rectosigmoid wall thickening consistent with inflammation, diverticula and a metallic-like object in the proximal sigmoid colon (Figurea). The patient was started on piperacillin-tazobactam and prepared for flexible sigmoidoscopy occurring next morning. Endoscopy revealed areas of multiple diverticula, surrounding ulceration and bleeding in the rectosigmoid colon (Figureb); cold biopsy was taken of the ulceration. A foreign body was found in the sigmoid colon (Figurec) and was successfully removed with a Roth Net. The foreign body appeared to be swallowed chicken bone. Biopsy showed cellular debris and colonic mucosa with acute and chronic inflammation. Pathology identified the object as a bone fragment. Discussion: The differential diagnosis of gastrointestinal bleeding is broad, but rarely is foreign body obstruction in the rectosigmoid region considered. The object must traverse 25 feet of small bowel prior to ulcerating the colon. The most common sites of complication occur at the ileocecal and rectosigmoid regions due to luminal narrowing and anatomic angulation. If complication occurs, 10-20% of foreign bodies can be removed endoscopically; 1% or less require surgical intervention. Intestinal strictures, cancer, diverticular disease, and hernias increase risk of complications after foreign body ingestion. Diverticulosis was the only identifiable risk factor in our patient case making it a unique clinical presentation.Figure 1.: Images from left to right (1a) foreign body as seen on admission CT (1b) sigmoid colon ulceration with diverticula seen proximal (1c) foreign body as seen on approach.

1978 Picking up the Pieces: Surgical and Medical Management of Retained Shattered Glass in the Rectum

INTRODUCTION: Retained rectal foreign bodies are an increasingly common presentation requiring emergent surgery. The object can often be retrieved at bedside. However, in the setting of a retained foreign body, especially one complicated by bleeding, perforation, or peritonitis, open surgery or laparoscopic assisted transanal retrieval is often needed. Careful investigation and a high index of suspicion is required as patients are often reluctant to share the etiology of their presentations. CASE DESCRIPTION/METHODS: A 55-year-old male presented to the ED with complaints of rectal bleeding. He stated he had placed a glass bottle in his rectum. Upon removal he noticed the top half of the bottle was retained inside his rectum. He developed mild rectal pain and bright red blood per rectum. On exam, there were no peritoneal signs. DRE revealed no perianal lesions, sphincter lacerations, or palpable foreign bodies. Initial labs displayed hemoglobin and hematocrit at 11.7 and 34.1, respectively. CT showed multiple radiopaque foreign bodies in the distal rectosigmoid measuring up to 14 cm in length with presacral edema. Proctoscopy was performed in the OR. Glass which was readily removable via a transanal approach was retrieved, while larger perforating pieces were carefully mobilized proximally and retracted via laparotomy. Sigmoidoscopy confirmed complete removal with multiple deep lacerations and perforations in the rectal wall. On post-op day seven, large volume rectal and mucus fistula bleeding with severe hypotension, tachycardia, change in mental status and a drop in hemoglobin to 5.8 occured. MTP was activated with administration of a total of five units of PRBC and two units of FFP. Colonoscopy was performed in the OR. An ulcer containing a pulsating, protruding, visible vessel was actively bleeding. Two clips were placed over the vessel with no further episodes of bleeding. Three months postoperatively barium enema was performed showing no leaks leading to reversal of colostomy. DISCUSSION: A retained rectal foreign body is not commonly the cause of a surgical emergency. Post-op complications, such as rectal bleeding, are rare and are normally handled by a return to the OR to control the source. Colonoscopy after a perforating rectal injury may be considered to evaluate and stop the source of postoperative bleeding, thus avoiding additional surgery and decreasing recovery time. Additionally, DRE should be cautioned when suspecting sharp hazardous material at an undetermined height in the colorectal tract.

1539 Drug-Induced Colitis as a Side Effect of Calcitonin Gene-Related Peptide (CGRP) Antagonist for Migraines

INTRODUCTION: Drug-induced colitis is a documented though relatively uncommon side effect of several drug classes, and is under-recognized and under-reported. In May 2018, an injectable calcitonin gene-related peptide (CGRP) antagonist, erenumab, was approved by the FDA for migraine prophylaxis. In the following case, this new medication is implicated as a possible cause for severe colitis resembling an inflammatory bowel disease-like picture both clinically and endoscopically. CASE DESCRIPTION/METHODS: A 33-year-old Caucasian female presented with complaints of rectal bleeding, diarrhea, and abdominal pain 2 weeks after starting a CGRP antagonist, erenumab, for chronic refractory migraine headaches. Pertinent laboratory studies showed leukocytosis with bandemia. CT Abdomen/Pelvis showed diffuse colonic wall thickening. Stool studies did not indicate any infectious etiology and an IBD panel was negative. She underwent a colonoscopy that showed severe, deep punched out ulcerations throughout the entire colon. Biopsy showed active colitis. She had a prior colonoscopy in 2009 for work up of IBS, which was endoscopically and microscopically normal. The patient's symptoms and clinical findings resolved after discontinuing the drug. A follow up colonoscopy performed one month after discharge showed evidence of ulcer healing with no new areas of inflammation. DISCUSSION: Blocking CGRP receptors of the central nervous system may reduce headaches, however blocking those of the enteric system can promote breakdown of the colonic mucosal barrier and induce a systemic inflammatory reaction. In animal models, extensive mucosal damage was noted in the subjects receiving CGRP receptor antagonists. This case implies that certain patients may be at risk for developing mucosal barrier disruption from the blockade of the calcitonin gene-related peptide receptor with erenumab or similar drugs. Further research may be needed to elucidate risk factors that may contribute to susceptibility to these deleterious effects. Once those patients that are more at risk are identified, there may be a role for endoscopic surveillance in certain patients taking these medications. While drug-induced colitis is likely to be an uncommon manifestation of blocking CGRP, clinicians should be aware of this potential side effect of targeted therapy and counsel patients receiving this therapy.

Rare Case of Metastatic Colorectal Cancer to Uretral Meatus with Rapid Progression and Fatal Outcomes

Urethral metastases are extremely rare. A few cases of uretral metastasis in the literature have been found to arise from the colon. Because of the rarity of uretral metastasis and its similarity to primary uretral neoplasms, diagnosis is rarely evoqued. We report here a case of a 46-yearold female admitted to our hospital with complaints of rectal bleeding, bowel distension and urinary symptoms. Clinical examination revealed rectal mass associated with meatus urethral tumor. A biopsy yielded a diagnosis of rectal adenocarcinoma with metastasis to urethral meatus, and tumor cells were strongly and uniformly positive for CK20 and CDX2 at immunohistochemical analysis. A general examination has shown a sigmoid tumor with hepatic metastatic lesion. One month after diagnosis, the tumor grew rapidly, with hepatic invasion and therefore the patient was treated only by palliative care. She died from liver failure one month later. Although urethral metastasis originating from colon is rare, this entity is increasingly described. The synchronous character and the location of the metastasis in the uretral meatus, are two remarkable characteristics described in this case report. The purpose of presenting this case report is to raise awareness among clinicians to consider this clinical entity as a differential diagnosis when urethral mass is identified.

Three-Year Experience With Rectal Prolapse Patients

BackgroundRectal prolapse (RP) is a rare condition characterized by rectums protrusion through the anus with all of its layers. RP is a condition deteriorating the quality of life. Although more than 100 surgical procedures were described so far for the treatment of RP, the ideal treatment method still remains unclear. In this study, demographical data and clinical results of 13 patients who were treated at our clinic for RP for a period of 3 years were retrospectively studied, with the aim of comparing with the results of other repair methods mentioned in the literature.MethodsTotal of 13 patients admitted to the general surgery unit and the emergency units between January 2008 and December 2010 were included in the study. All of the cases were treated by modified Notoras technique using various synthetic materials.ResultsOf the patients, 8 were male, and 5 were female. Average age was 45.6 years (range: 23 - 79 years), and the average hospitalization time was 11.3 days (range: 3 - 19 days), with the symptom time being an average of 12 years (range: 1 - 30 years). All patients having complaints described mass prolapsing from the anal canal during defecation, rectal pain, and constipation. Six of our patients also had complaints of rectal bleeding. Average follow-up time was 24 months. No recurrence and mortality were monitored in patients who were followed.ConclusionsThe main purposes in the surgical treatment of RP were to control the prolapse, and to achieve continence and remedy constipation. We believe that the modified Notoras technique made using synthetic materials the most suitable one compared to other rectopexy methods in the treatment of RP because it is safe and easily applicable.KeywordsRectal prolapse; Rectopexy; Modified Notoras technique

A Rare Cause of Rectal Bleeding!

Purpose: The presence of gastric mucosa in the rectum is an extremely rare clinical entity with only 29 cases reported in the English literature. Heterotopia refers to the displacement of an organ or part of an organ from its normal site. Heterotopia is the result of primary displacement or a developmental abnormality where the foreign tissue is termed “heterotopia.” Gastric heterotopia in the rectum can clinically present with hematochezia, but other complications such as rectovesical and anocutaneous fistula have been reported. We report a rare case of gastric heterotopia of rectum accompanied by a brief review of the available literature. Methods: Chart review and review of literature using Medline and relevant bibliographies. Results: A 49 year old man was referred to the gastroenterology clinic with complaints of rectal bleeding since three months. Approximately 18 months ago, the patient had a normal colonoscopic exam which was performed as a work up for abnormal bowel habits. Upon presentation, a repeat colonoscopy revealed a 3 mm sessile polyp in the distal rectum. No other anorectal pathology was evident to explain the symptoms of hematochezia. The rectal polyp was resected using electrocautery snare. The pathology report of the polyp showed fragments of gastric mucosa suggestive of heterotopia. Conclusion: The common presentations of gastric heterotopia of rectum are rectal bleeding and tenesmus, but patients may present with abdominal pain or incidental mass on colonoscopy. Hematochezia usually responds to treatment with histamine 2 receptor blockers, but endoscopic or surgical excision is the treatment of choice. The literature suggests that even an incidentally discovered gastric heterotopia of rectum in an asymptomatic patient should be removed in view of possible complications such as malignant degeneration and fistula formation.[figure1][figure2]FigureFigure

Simultaneous Laparoscopic Treatment for Rectosigmoid and Ileal Endometriosis

Endometriosis is common in women of childbearing age, while severe intestinal endometriosis requiring bowel resection is relatively rare. Intestinal endometriosis has recently been managed laparoscopically. We report the case of a 38-year-old patient with rectosigmoid and ileal endometriosis who was successfully treated by laparoscopic bowel resections. The patient had first presented at age 34 years with a chief complaint of rectal bleeding and lower abdominal pain related to the menstrual cycle. She underwent laparoscopic surgery and was diagnosed with severe endometriosis involving the rectosigmoid colon. Although an additional laparoscopic surgery had been planned, she did not return to the hospital. When she was 38 years old, she presented again with the same symptoms. Magnetic resonance imaging revealed a low intensity mass between the uterus and the rectosigmoid colon. A barium enema showed a stenotic site in the rectosigmoid colon. After hormone therapy, she underwent laparoscopic surgery. The anterior wall of the rectosigmoid colon adhered firmly to the corpus of the uterus, and another stenotic site was identified at the terminal ileum. The rectosigmoid colon and ileum were partially resected under laparoscopy. The postoperative course was uneventful and she was freed of symptoms. Laparoscopic treatment for patients with severe endometriosis of the bowel has becomes feasible and safe.

Rectal Bleeding in the Pediatric Emergency Department

Study objectives: To describe the presumptive diagnoses in an unselected, ambulatory, pediatric population complaining of rectal bleeding; to determine how often those diagnoses changed with follow-up; and to determine how often the bleeding represented an acutely life-threatening condition. Design: Retrospective case series. Setting: Urban, tertiary care pediatric emergency department. Participants: One hundred four patients with 109 visits with a chief complaint of blood in the stool. Interventions: None. Main results: Follow-up was available on 95 of 109 visits (87.1%), with a mean duration of 7.5 months. A specific presumptive etiology was established for 73 of 109 patients (67%) at the initial ED visit and for 74 of 95 patients (77%) at follow-up. The etiologies varied markedly by age. Four patients (4.2%; 95% confidence interval, 0.2% to 8.2%) presented with a life-threatening condition (requiring an RBC transfusion or operative intervention): intussusception (three patients) and Meckel's diverticulum (one patient). Concordance between the ED diagnosis and the follow-up diagnosis was 81%. Conclusion: A complaint of rectal bleeding is typically not life threatening in children. Emergency physicians normally are able to establish a presumptive diagnosis, which usually remains the same with follow-up. [Teach SJ, Fleisher GR: Rectal bleeding in the pediatric emergency department. Ann Emerg Med June 1994;23:1252-1258.]

Clinical Features, Evaluation, and Detection of Colorectal Cancer

The most common presentation of colorectal carcinoma is in the symptomatic patient, most often with complaints of rectal bleeding, abdominal pain, or change in bowel habits. Symptomatic patients often have advanced disease and, because surgical resection is the only effective therapy at present, their chance for cure is poor. Until effective treatment is available, therefore, we must identify patients at high risk for lifelong screening. In addition, more effective means of surveillance of the general population need to be developed in order to diagnose patients at risk for sporadic colorectal cancer, given that this represents the majority of patients with disease. Tumor markers also would be useful to find residual disease while it is still resectable in patients who have undergone surgery for curative resection.

Colitis Cystica Profunda

Colitis cystica profunda is a benign condition which may mimic carcinoma of the colon from both a radiologic and a pathologic standpoint. The lesion is characterized by intramural mucus-containing cysts, usually localized to the rectosigmoid region. The patients are young adults who often present with complaints of rectal bleeding and/or mucus in the stool. Microscopically, the cysts lie deep in the muscularis mucosae, differing from the superficial lesions of colitis cystica superficialis seen in patients with sprue and pellagra. Normal colonic epithelium lines the cysts, and the intraluminal mucin stains basophilic with hematoxylin and eosin. Evidence of chronic inflammation often accompanies the cysts. Grossly, the bowel wall appears thickened, and nodular polypoid foci are sometimes seen on proctoscopic examination. Small ulcerations may be present on the overlying mucosa. The roentgen picture is one of an intraluminal nodular space-occupying lesion or lesions. Out-pouchings of barium may be present, suggesting ulceration. The first report in the American medical literature by Epstein et al. (1) described four cases of this condition. They postulated that “the lesion probably results from herniation of colonic mucosa through a muscularis mucosae which is congenitally weak or damaged by an inflammatory disease; or perhaps is the result of re-epithelization of deep undermining ulcers.” Brynjolfsson and Haley (2) also attempted to elucidate the pathogenesis of this lesion by experimental work in rats. Additional cases have been reported from the Massachusetts General Hospital (3) and from the Armed Forces Institute of Pathology (4). Allen (5) reported three cases of “hamartomatous inverted polyps of the rectum,” all showing the features described in colitis cystica profunda. We recently encountered a case of this condition which illustrates well the roentgen characteristics of a nodular polypoid mass in the rectum on barium enema examination (Fig. 1). We feel that a report of this condition in the radiologic literature is indicated to ensure that radiologists are aware of the lesion and to stress the need to differentiate it from more ominous conditions in the rectosigmoid area. This 23-year-old Caucasian female registered nurse visited her physician with a complaint of spotty rectal bleeding that was not associated with any other signs or symptoms. She had been in good health, but her anxiety was now heightened because only three months earlier an adenocarcinoma of the rectum had been discovered in her mother. Sigmoidoscopy revealed a thickened mucosal area, measuring 1.5 × 1.5 cm in diameter, on the anterior wall of the rectum at the level of the cervix uteri. The mucosa appeared intact, but suggestive of possible underlying inflammation. The lesion was biopsied through the sigmoidoscope. Microscopic sections (Fig. 2) showed continuation of the colonic mucosa into a mucin-producing cyst within the muscularis mucosae.