Recurrent Rectal Bleeding Research Articles

Management of Hematochezia in Blue Rubber Bleb Nevus Syndrome

Intro: Blue Rubber Bleb Nevus syndrome (BRBNS) is a rare disease that is characterized by mucocutaneous venous malformations that most commonly affect the skin and gastrointestinal (GI) tract. We present a case report describing the therapeutic challenges of managing a GI bleed secondary to BRBNS.Figure: Numerous blue rubbery papules located on the patient's a) right thigh b) left thigh and c) right foot.Figure: Smaller blebs scattered throughout the colon.Figure: Colonoscopy showing a large bleb in the ascending colon.Case Report: A 41-year-old female patient with a history of BRBNS presented to our clinic with a complaint of spontaneous rectal bleeding, requiring her to wear a pad everyday for the past 5 months. Physical exam was notable for scattered blue nodules on her thighs and right foot (figure 1). Labs were significant for a hemoglobin of 10.4 g/dL, platelets of 118 K/uL, fibrinogen of < 80 mg/dL. On colonoscopy, a dozen blue rubber blebs were located throughout the colon (figure 2). The most erythematous and prominent bleb, which measured 1.5 cm, was believed to have been the culprit of her recurrent rectal bleeding and anemia, and thus was the target for intervention (figure 3). The lesion was suctioned into the banding apparatus, but the attempt to deploy a band merely resulted in spontaneous albeit self-limited bleeding. While lavaging the decompressed bleb, a second neighboring bleb began to actively bleed. Injection with both 6 cc of epinephrine and 2 mL of butyl-2-cyanoacrylate glue slowed but did not cease the hemorrhage. Band ligation was then employed on this second bleb, and hemostasis was achieved. Because of the risk of underlying DIC, the patient received 10 units of cryoprecipitate. No further bleeding was reported at a ten day follow-up. Discussion: As demonstrated, successful banding may be difficult giving the large size of the blebs. Injecting glue into the bleb did not result in hemostasis, and still required additional banding to stop the active bleed. Although it is not typical, this technique of injecting glue may have helped change the consistency of the lesion, creating solidification and making banding more successful. In patients with chronic DIC, as in our case, periprocedural hematologic support with platelets and cryoprecipitate may help in the setting of active bleeding. Surgery, as well as the use of interferon, octreotide, or sirolimus may be considered in cases of refractory bleeding. Conclusion: Management of BRBNS is challenging because there is no cure or treatment guidelines and experience is limited to case reports. More studies are needed to elucidate the most effective hemostasis strategy for bleeding lesions in BRBNS.

Acute Atherothrombotic Disease and Severe Bleeding: A Difficult Clinical Presentation in Medical Practice

Management of antithrombotic therapy in elderly patients with unstable atherothrombotic disease and increased risk of bleeding is a major clinical challenge. We report the case of a 79 year- old diabetic man with rheumatoid arthritis on both oral corticosteroids and NSAID therapy with mild renal dysfunction, who presented to our hospital because of disabling claudication. Prior to admission he had several episodes of TIA. He also had recurrent small rectal bleeding and mild anemia attributed to his long-standing hemorrhoid disease. Angiography showed a sub-occlusive left internal carotid artery stenosis associated with a significant LAD stenosis and complex peripheral artery disease. Cataclysmic bleeding and hemorrhagic shock occurred in the third day post admission. Withdrawal of all antithrombotic treatment, blood transfusion and emergency sigmoidectomy were performed for bleeding colonic diverticulosis. Subsequently antiplatelet therapy was reinitiated and the patient successfully underwent left carotid artery endarterectomy and LAD stenting. He was discharged from hospital on the 21(st) day post admission and is doing well at 24 months follow-up.

Recurrent Rectal Bleeding in a Patient With Angiosarcoma of the Colon

Recurrent Rectal Bleeding in a Patient With Angiosarcoma of the Colon

Crohnʼs Disease, Malignant Melanoma, and Churg-Strauss Syndrome: A Treatment Dilemma

A 71-year-old man with Churg-Strauss disease on low-dose prednisone (prior azathioprine use), diabetes, atrial fibrillation, and diverticular disease presented with hematochezia, pain with defecation, & increased stool frequency. He denied abdominal pain, fever, nausea, emesis, weight loss, constipation, joint pains, skin rash or eye pain. Vital signs were normal, abdomen was soft, non-tender, non-distended, and rectal examination revealed perianal irritation and significant pain without fistulae. Laboratory studies revealed elevated CRP of 92.8 mg/L (normal C. difficile, Shigella PCR and stool culture. A CT abdomen revealed 5-10 cm concentric wall thickening in the sigmoid colon with associated pericolonic mesenteric hyperemia. Colonoscopy revealed nodularity and irregularity in the rectum and an inflammatory stricture in the sigmoid colon with deep ulcerations, and pathology revealed active chronic colitis with ulceration. Of note, a colonoscopy 5 months prior was normal. Treatment with aminosalicylates was unsuccessful and due to unclear diagnosis and concern for malignancy, laparoscopic sigmoid resection with primary anastomosis was performed. Surgical pathology showed moderately active chronic colitis with creeping fat, stricture formation, transmural chronic inflammation, and granulomas consistent with Crohn's disease. Six months later, he developed recurrent rectal bleeding and colonoscopy revealed moderately ulcerated rectal mucosa and mild inflammation of his colonic anastomosis consistent with moderately active Crohn's disease. In the interim, he underwent excision of a mole on his back and pathology was consistent with malignant melanoma. Therefore, the decision was made to defer anti-TNF therapy and the patient was treated with vedolizumab, a gut selective antiintegrin molecule. In addition to typical dermatologic manifestations such as pyoderma gangrenosum and erythema nodosum, patients with inflammatory bowel disease (IBD) are at increased risk for non-melanoma skin cancers and malignant melanoma. A meta-analysis revealed that IBD was associated with an increased risk of malignant melanoma, independent of treatment with biologic therapy, and is increased with anti-TNF treatment and immunomodulatory medications. In contrast, since vedolizumab selectively blocks gut leucocyte trafficking, it is likely to have lower systemic immunosuppression and lower risk for melanoma.

Factitious Disorder Manifesting as Hematemesis and Hematochezia.

To the Editor: According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,1 factitious disorder is characterized by (1) falsification of physical or psychological signs or symptoms by an individual, with the deception subsequently identified by others; (2) presentation of oneself as ill, impaired, or injured; and (3) absence of an obvious external or tangible reward for the behavior. A number of factitious physical symptoms and syndromes have been described in the extant literature, including but not limited to aortic dissection, cancer, chronic pain, deafness or blindness, hemiplegia, hemoptysis, human immunodeficiency infection, hypoglycemic coma, mydriasis, various neurologic syndromes, osteomyelitis, and quadriplegia.2 However, we were unable to locate a reported factitious case of combined hematemesis and hematochezia. In addition, the creation of signs and symptoms in this case were somewhat unique. Case report. Ms A was a 37-year-old woman with a past medical history of bipolar disorder, chronic anxiety, polysubstance abuse, chronic hepatitis with cirrhosis, esophageal varices, coagulopathy, and Crohn disease who presented with an acute episode of hematochezia. Hemoglobin level at admission was 11.5 g/dL. An initial esophagogastroduodenoscopy indicated no acute source of bleeding in the oral cavity, esophagus, stomach, or duodenum, yet fresh blood was found in the oropharynx after an episode of vomiting. A subsequent colonoscopy demonstrated shallow linear nonbleeding lesions and edema of the ascending colon that were inconsistent with inflammatory bowel disease. When the rectal bleeding ceased and hemoglobin level stabilized, the patient was discharged. Five days later, Ms A returned with recurrent rectal bleeding with a hemoglobin level of 11.1 g/dL. Flexible sigmoidoscopy indicated an increased number of linear ulcers in the same region as before, 2 of which were found to be bleeding immediately proximal to the anal verge. Overnight, the patient continued with persistent hematochezia accompanied by a 0.5 g/dL decrease in hemoglobin. A second flexible sigmoidoscopy was ordered. Prior to the procedure, as the patient was being positioned, a small serrated jackknife was found in the bedding just behind the patient. When confronted, the patient initially adamantly denied but then affirmed that the rectal lesions were self-inflicted. The patient explained that she inserted her finger into her rectum with the blade of the knife closely pressed against it, and then carefully made abrasions as deep as possible in her colon. She also confessed that the hematemesis was created through the ingestion of fresh blood from her intravenous line. A meaningful challenge in the diagnosis of factitious disorder is the extent to which the individual’s reported symptoms are due to choice or psychopathology.3 When factitious disorder is detected, intervention may be compromised by the patient’s unwillingness to cooperate as well as the lack of evidence-based treatment for this disorder. In terms of treatment, psychotherapy is recommended,4 although there is no evidence of efficacy for one treatment over another.5 Dialectical behavior therapy has been proposed.6 Overall, with the development of the Internet, factitious disorders will quite likely become more complex and primary care providers will very likely continue to be challenged. This case report illustrates the fortitude entailed in generating elusive symptoms.

Diffuse cavernous hemangioma of the rectum: magnetic resonance imaging features: a case report

Diffuse cavernous hemangioma of the rectum: magnetic resonance imaging features: a case report Diffuse cavernous hemangioma of the rectum (DCHR) is a rare benign vascular lesion usually seen in young adults. The presenting symptom is painless recurrent rectal bleeding. Herein, we report a 5 yearold male patient with a history of DCHR. He had been diagnosed with DCHR at his birth. The definite diagnosis was made on the basis of biopsy wich was performed during colonoscopic examination. The patient underwent magnetic resonance imaging (MRI) examination which revealed characteristic signal intensity features of the tumor and also determined the exact location and extent of the lesion. The tumor had only minimally progressed in size compared to the last MRI examination. Currently, the patient is on medical treatment and being followed up by MRI. DCHRs are rarely encountered and often misdiagnosed because they can mimic internal hemorrhoids, inflammatory bowel disease, carcinoma and various other pathological conditions. In conclusion, we can emphasize that despite its rarity, DCHR should be considered in the differential diagnosis of young patients presenting with

Multiple Ganglioneuromatous Polyps of the Colon: What Lies Beneath the Surface of Colon?

Purpose: Ganglioneuromatous polyps of the colon are rare. They are seen in neurofibromatosis, multiple endocrine neoplasia (MEN) type IIb, phosphatase and tensin homolog (PTEN) gene mutations and tuberous sclerosis. Case: A 25-year-old healthy Caucasian female had been suffering from recurrent rectal bleeding. Her family history included early onset uterine cancer, and total abdominal hysterectomy and thyroidectomy in her sister; her mom had bilateral breast cancer at 46. Physical exam showed body mass index (BMI) of 34, macrocephaly, papules over the left nostril, right and left hand. The rest of the examination was unremarkable. Initial lab work-up including CBC, metabolic panel and infectious diarrhea was unremarkable. She underwent a colonoscopy with biopsy that revealed ganglioneuromatous polyps. EGD showed multiple papules and Brunner gland hamartomas. DNA revealed heterozygous mutation in one copy of the PTEN gene mutation, which corroborated the clinical diagnosis of Cowden syndrome. Cowden syndrome is a rare genetic disorder occurring in one in 1,000,000 people. Since this is quite a rare disorder, patients may not be diagnosed until their 20s or 30s. Lesions in this syndrome could arise from any of the three germ cell layers. Reports of ganglioneuromas of the colon seen in this patient are quite rare. Colon polyps stained with hematoxylin and eosin stain showed spindle cell proliferations, which were positive for S-100 and neuron-specific enolase, indicating neural crest origin of these tumors. This case demonstrates that this disorder could be more frequent than is currently estimated. A combination of macrocephaly and recurrent gastrointestinal bleeding with skin manifestations should raise suspicions for this disorder. Due to its autosomal inheritance pattern, all family members who have macrocephaly should be evaluated. Screening is important, as there is increased risk for breast (85%), thyroid (35%) and endometrial (28%) cancer. Usual GI manifestations include colorectal hamartomas with esophageal glycogenic acantholysis (seen in this patient), which could be as high as 85%.Table. ICCC: criteria for Cowden syndromeFigure: Colonic mucosa with spindle cell proliferation essentially replacing the lamina propria between crypts (200x).

Transjugular Intrahepatic Portosystemic Shunt (TIPS) for the Treatment of Anorectal Varices

Purpose: Despite the high prevalence of anorectal varices in portal hypertension, serious hemorrhage is quite rare, but may be fatal. Although several techniques for treating acute bleeding have been reported, the optimal therapeutic management has not been established. We report a patient with severe recurrent rectal bleeding from anorectal varices successfully treated by a transjugular intrahepatic portosystemic shunt (TIPS). A 53-year-old man with known history of hepatitis C-induced liver cirrhosis, listed for possible liver transplantation and prior decompensation in the form of esophageal variceal bleed maintained on beta-blockers, presented to the emergency department with the chief complaint of rectal bleeding for one week's duration, associated with weakness, dizziness, shortness of breath, and generalized abdominal pain. On admission, labs showed: WBC 1.3, hb 10.4, hct 31.4, INR 1.5, total bilirubin 1.4, alkaline phos 136, ALT 43, AST 70. CT abdomen and pelvis performed the day of admission revealed: diffuse cirrhosis without hepatic lesion, splenomegaly, large-caliber gonadal varices that extend to the pelvis and surround the rectum, as well as concentric thickening of the rectum. Due to presentation and findings, gastroenterology was consulted. EGD showed grade 2 esophageal varices without stigmata of recent bleeding, and gastric antral vascular ectasia (GAVE) without active bleeding. Colonoscopy showed very large rectal varices. One column had a small mucosal hemorrhage present, no active bleeding esd present, and a nonbleeding cecal AVM. After extensive discussion between the hepatology and GI departments about options for treatment, it was decided to pursue transjugular intrahepatic portal systemic shunt (TIPS) to relieve portal pressure causing the rectal varices. The patient underwent successful TIPS procedure, performed by the interventional radiology department. Contrast injections during the examination demonstrated hepatofugal flow in the portal vein. The patient was also noted to have splenorenal shunting, as well as massive inferior mesenteric vein filling rectal varices. A Rosen wire was placed. The tract was dilated to 8 mm. A 10-mm x 80-mm covered VIATORR stent was placed. Follow-up pressures demonstrated a mean portal pressure of 29 mmHg with a central venous pressure of 29/22, with a mean of 25 mmHg. There remained flow in the inferior mesenteric vein; however, it subjectively appeared to be slower. After the procedure, the patient was discharged to be followed closely as an outpatient. A follow-up colonoscopy was performed two months after TIPS procedure. showing one cord of rectal varices, approximately 75% improved since prior colonoscopy, and small internal hemorrhoids.

Solitary Juvenile Polyp

Juvenile polyps are one of the most common sources of gastrointestinal bleeding in childhood. These polyps are nonneoplastic hamartomas that occur in up to 2% of children. The author presents the case of an 8-year-old boy with recurrent rectal bleeding due to a singular juvenile polyp. This article is part of an expert video encyclopedia.

Successful treatment with transjugular intrahepatic portosystemic shunt (TIPS) of recurrent massive rectal bleeding due to portal hypertension: Case report

Bleeding from anorectal varices can be massive and life-threatening. Punctual separation between hemorrhoids and anorectal varices is important. Numerous treatment options are available for management of bleeding anorectal varices, but none of them has demonstrated definitive efficacy. We report a case of successful transjugular intrahepatic portosystemic shunt in controlling massive recurrent rectal variceal bleeding in an elderly male patient.

Peutz-Jeghers syndrome: capsule endoscopy to stage disease

A 13-year-old girl with recurrent abdominal pain and rectal bleeding was referred to our department. Her 36-year-old father had been diagnosed with Peutz-Jeghers syndrome (PJS) after previous surgical interventions for intestinal occlusion. On physical examination, she had hyperpigmented macules on her lips and buccal mucosa. Genetic testing showed a mutation in exon 6 of the gene STK11. A video capsule endoscopy was done to stage the disease. A 7 mm polyp in the stomach (figure A; video 1), and a 12 mm pedunculated polyp in the proximal jejunum, were seen (figure B; video 2).

120 Roles of PKCs and PKD in Mechanotranscription in Colonic Smooth Muscle Cells: Inhibition of Mechanotranscription as a Potential Treatment for Motility Dysfunction in Obstructive Disorders

Background: Acute lower gastrointestinal bleeding (LGIB) accounts for about 30 percent of episodes of gastrointestinal bleeding. It encompasses a wide spectrum of symptoms ranging from trivial hematochezia to massive hemorrhage with shock. Identifying those who will later develop severe bleeding is a challenge. Strate and colleagues have identified predictors of severity in patients with acute lower intestinal bleeding. The aim of this study was to provide external validation for the Strate clinical prediction rule for severe acute LGIB. Methods: We retrospectively selected patients with a principal diagnosis of LGIB between January 2007 and August 2011 at a busy urban hospital. Predictor variables were those from Strate's original study: heart rate ≥ 100/min, systolic blood pressure ≤ 115 mmHg, syncope, nontender abdominal exam, rectal bleeding in the first 4 hours of evaluation, aspirin use, and >2 comorbid conditions. Severe LGIB was defined as the presence of any of the following: transfusion of ≥2 units of red blood cells in the first 24 hours, recurrent rectal bleeding after 24 hours of stability (requiring additional blood transfusions), need for ICU placement or readmission for acute LGIB within one week of discharge. An overall risk score was created by adding the number of predictive factors present. Patients were stratified into 3 risk groups: low (no risk factors), moderate (1-3 risk factors), and high (>3 risk factors). Results: Analysis was performed on 378 patients. The risk of severe bleeding in each category was: low risk 31%, moderate risk 55%, and high risk 84%. The area under the receiver operating characteristic curve (AUROC) was 0.70 with good calibration (H-L chi sq.= 0.98). The magnitude of the risk score was significantly correlated with need for blood transfusions, ICU placement and length of stay but not with need for surgery or death. Inclusion of additional variables including age, gender, actual heart rate and systolic blood pressure did not improve the AUROC for the prediction of severe bleeding. Conclusions: Strate and colleagues developed a promising clinical prediction rule for acute severe LGIB. The risk factors are simple and available within 4 hours of presentation. However, we find the predictive ability of the rule to be lower than in the original study as evidenced by the lower AUROC (0.70 versus 0.75). The Strate LGIB score does not have sufficient discriminatory power to improve the triage of patients to appropriate levels of care, nor promote a more standardized approach to acute LGIB. Further research is needed to improve our ability to identify patients presenting with LGIB who are at high risk for severe bleeding.

122 Cholecystokinin-8 Regulates Pacemaker Activities in Cultured Interstitial Cells of Cajal From Murine Small Intestine

Background: Acute lower gastrointestinal bleeding (LGIB) accounts for about 30 percent of episodes of gastrointestinal bleeding. It encompasses a wide spectrum of symptoms ranging from trivial hematochezia to massive hemorrhage with shock. Identifying those who will later develop severe bleeding is a challenge. Strate and colleagues have identified predictors of severity in patients with acute lower intestinal bleeding. The aim of this study was to provide external validation for the Strate clinical prediction rule for severe acute LGIB. Methods: We retrospectively selected patients with a principal diagnosis of LGIB between January 2007 and August 2011 at a busy urban hospital. Predictor variables were those from Strate's original study: heart rate ≥ 100/min, systolic blood pressure ≤ 115 mmHg, syncope, nontender abdominal exam, rectal bleeding in the first 4 hours of evaluation, aspirin use, and >2 comorbid conditions. Severe LGIB was defined as the presence of any of the following: transfusion of ≥2 units of red blood cells in the first 24 hours, recurrent rectal bleeding after 24 hours of stability (requiring additional blood transfusions), need for ICU placement or readmission for acute LGIB within one week of discharge. An overall risk score was created by adding the number of predictive factors present. Patients were stratified into 3 risk groups: low (no risk factors), moderate (1-3 risk factors), and high (>3 risk factors). Results: Analysis was performed on 378 patients. The risk of severe bleeding in each category was: low risk 31%, moderate risk 55%, and high risk 84%. The area under the receiver operating characteristic curve (AUROC) was 0.70 with good calibration (H-L chi sq.= 0.98). The magnitude of the risk score was significantly correlated with need for blood transfusions, ICU placement and length of stay but not with need for surgery or death. Inclusion of additional variables including age, gender, actual heart rate and systolic blood pressure did not improve the AUROC for the prediction of severe bleeding. Conclusions: Strate and colleagues developed a promising clinical prediction rule for acute severe LGIB. The risk factors are simple and available within 4 hours of presentation. However, we find the predictive ability of the rule to be lower than in the original study as evidenced by the lower AUROC (0.70 versus 0.75). The Strate LGIB score does not have sufficient discriminatory power to improve the triage of patients to appropriate levels of care, nor promote a more standardized approach to acute LGIB. Further research is needed to improve our ability to identify patients presenting with LGIB who are at high risk for severe bleeding.

119 Validation of a Predictive Rule for Severe Acute Lower Intestinal Bleeding

Background: Acute lower gastrointestinal bleeding (LGIB) accounts for about 30 percent of episodes of gastrointestinal bleeding. It encompasses a wide spectrum of symptoms ranging from trivial hematochezia to massive hemorrhage with shock. Identifying those who will later develop severe bleeding is a challenge. Strate and colleagues have identified predictors of severity in patients with acute lower intestinal bleeding. The aim of this study was to provide external validation for the Strate clinical prediction rule for severe acute LGIB. Methods: We retrospectively selected patients with a principal diagnosis of LGIB between January 2007 and August 2011 at a busy urban hospital. Predictor variables were those from Strate's original study: heart rate ≥ 100/min, systolic blood pressure ≤ 115 mmHg, syncope, nontender abdominal exam, rectal bleeding in the first 4 hours of evaluation, aspirin use, and >2 comorbid conditions. Severe LGIB was defined as the presence of any of the following: transfusion of ≥2 units of red blood cells in the first 24 hours, recurrent rectal bleeding after 24 hours of stability (requiring additional blood transfusions), need for ICU placement or readmission for acute LGIB within one week of discharge. An overall risk score was created by adding the number of predictive factors present. Patients were stratified into 3 risk groups: low (no risk factors), moderate (1-3 risk factors), and high (>3 risk factors). Results: Analysis was performed on 378 patients. The risk of severe bleeding in each category was: low risk 31%, moderate risk 55%, and high risk 84%. The area under the receiver operating characteristic curve (AUROC) was 0.70 with good calibration (H-L chi sq.= 0.98). The magnitude of the risk score was significantly correlated with need for blood transfusions, ICU placement and length of stay but not with need for surgery or death. Inclusion of additional variables including age, gender, actual heart rate and systolic blood pressure did not improve the AUROC for the prediction of severe bleeding. Conclusions: Strate and colleagues developed a promising clinical prediction rule for acute severe LGIB. The risk factors are simple and available within 4 hours of presentation. However, we find the predictive ability of the rule to be lower than in the original study as evidenced by the lower AUROC (0.70 versus 0.75). The Strate LGIB score does not have sufficient discriminatory power to improve the triage of patients to appropriate levels of care, nor promote a more standardized approach to acute LGIB. Further research is needed to improve our ability to identify patients presenting with LGIB who are at high risk for severe bleeding.

Les cancers colorectaux au Sénégal : analyse d’une série monocentrique de 46 cas

Sub-saharian Africa has long been considered an area of low colorectal cancer risk. However, this pathology is increasingly encountered in hospital practice in Senegal. We wanted to take stock of colorectal cancerin a surgical environment. Patients and Methods: We report a descriptive study over a period of 5 years (January 2005 - December 2009), involving patients in care for colorectal cancer in the general surgery department of the General Hospital of Grand-Yoff. The parameters studied were the epidemiological profile, the elements of diagnosis, care and patient outcomes. Results: We collected 46 cases of colorectal cancer but a study period of 5 years, an average of 9.2 new cases per year. They were 30 men and 16 women with a mean age of 50.5 years. The average duration of clinical symptoms was 17 months. The clinical manifestations are dominated by revealing acute intestinal obstruction and chronic constipation. Tumors were colic in 71.7% of cases and rectal in 28.3% of cases. Histology showed a predominance of lieberkühnian adenocarcinoma (93.50%), mostly well differentiated. Patients in the series according to the classification (UICC 2002) were as follows: stage I (4.34%), stage II (39.13%), stage III (19.56%) and stage IV (36.95%). The overall operability rate was 84.8%. The overall resectability rate was 63%. The patients received chemotherapy in 43.47% of cases and by radiotherapy in 17.4% of cases. The overall operative morbidity was 17.9%. Operative overall mortality was 6.52%. Overall survival was 82.9% at one year, 61.4% at two years and 50.6% three years. Conclusion: Colorectal cancer is a reality in our practice of gastrointestinal oncology. The young age of our patients and the majority of advanced stages suggest particular attention to any recurrent rectal bleeding or constipation. Improving the prognosis will require the extension of haemocult even complete colonoscopy immediately before any chronic constipation.

Argon plasma coagulation and hyperbaric oxygen therapy in chronic radiation proctopathy, effectiveness and impact on tissue toxicity

chronic radiation proctopathy (CRP) is associated with recurrent rectal bleeding and transfusional requirements. Argon plasma coagulation (APC) and hyperbaric oxygen therapy (HOT) have been shown to be effective in the control of CRP. No prospective comparisons have been reported between these treatments. the aim was to evaluate the effectiveness, safety and impact on tissue toxicity of APC compared to HOT in patients with CRP. a prospective study for evaluating treatment response was conducted. Patients with cervical cancer and CRP with rectal bleeding were recruited. They had not received previous treatment. Collected data included: demographics, previous radiation dosage, duration and severity of rectal bleeding. Hemoglobin, transfusional requirements, and tissue toxicity (SOMA LENT questionnaire) at baseline and at 1, 2, and 3 months follow up were recorded. thirty-one patients were included, 14 in the APC group and 17 in the HOT group. No response was noted in 13 and 18% of patients in the APC and HOT group respectively (p = NS). At the 1 and 2 months follow-up, the APC group showed a significantly better response in terms of transfusional requirements (0.6 vs. 3.4 and 0.7 vs. 2.5) and tissue toxicity score (5.3 vs. 8.6 and 3.8 vs. 7.248). After 3 months, both groups showed further improvement in all parameters without significant differences between them. APC and HOT were effective, safe and decreased the tissue toxicity scores in patients with CRP. However, response rate was higher and faster in the APC group.

Laparoscopic-assisted bowel resection with construction of a colonic reservoir for cavernous hemangioma of the rectum: report of two cases

Diffuse cavernous hemangioma of the rectum is an unusual benign vascular lesion, marked by delayed diagnosis and often presenting recurrent rectal bleeding and anemia. Colorectal resection with coloanal anastomosis and construction of a colonic reservoir is the preferred surgical treatment. We report two cases of patients, a 23-year-old man and a 27-year-old woman, with cavernous hemangioma of the rectum, diagnosed by colonoscopy and confirmed by magnetic resonance imaging. Arteriography demonstrated vascular tumors in the rectal wall. Use of the embolization technique was not successful, since no large caliber vessel was available for this procedure. The patients underwent anterior abdominal excision of the rectum with a laparoscopic approach+ colonic reservoir and hand sewn coloanal anastomosis. Ileostomy closure was performed in both patients at 3 months after surgery, and they demonstrated good early and late postoperative outcomes. In summary, laparoscopic-assisted bowel resection may be a good option for surgical management of diffuse cavernous hemangioma of the rectum.

Argon plasma coagulation treatment of hemorrhagic radiation proctopathy: the optimal settings for application and long-term outcome

No standard treatment exists for hemorrhagic radiation proctopathy (HRP). Recently it was reported that argon plasma coagulation (APC) is effective for HRP. However, previous studies documented complications such as ulcers, strictures, and perforations in as many as 20% of APC-treated patients. The aim of this study was to determine the optimal parameters for APC by using swine rectum and to assess the safety and effectiveness of APC in HRP patients. Prospective case series. University teaching hospital. Sixty-five patients with HRP were prospectively enrolled between 2000 and 2010. APC for HRP. Optimal APC parameters, number of treatments, success rate, complications, clinical remissions. APC in swine rectal wall ex vivo was optimal with a 40-W current, 1.2-L/min gas flow rate, and 2-second application, which was sufficient to treat the submucosal telangiectasia but did not adversely affect the muscle layer. Sixty-five patients (46 men, 19 women; median age 72 years) with HRP occurring at a mean of 20 months after radiotherapy were studied. Proctopathy was classified as grade A (mild) in 7 patients (10.8%), grade B (moderate) in 41 (63.1%), and grade C (severe) in 17 (26.2%). The treatment success rate was 98.5% after a median of 2 (range 1-5) APC sessions. The median clinical score for rectal bleeding was significantly decreased after APC (P < .0001), and the hemoglobin level was significantly increased (P < .0001). APC was well tolerated, and no significant side effects or complications occurred. During a mean follow-up of 34.6 months (range 3.6 -121.1 months), 4 patients (6.3%) had minor recurrent rectal bleeding and 60 (93.8%) remained in remission. Nonrandomized study. HRP treatment with optimal APC settings yields a high success rate and long-lasting clinical remission with no significant complications.

W1429: Effectiveness, Safety and Quality of Life of Argon Plasma Coagulation vs. Hyperbaric Oxygen Therapy in Chronic Radiation Proctopathy

Chronic radiation proctopathy (CRP) manifests as persistent and/or recurrent rectal bleeding and can be associated with anemia, transfusional requirements and hospitalization which translate into a diminished quality of life (QOL). Argon Plasma Coagulation (APC) and Hyperbaric Oxygen Therapy (HOT) have both been shown to be effective in the control of CRP. No prospective comparison has been reported between these treatments.

Solitary rectal ulcer syndrome presenting as polypoid mass lesions in a young girl

Solitary rectal ulcer syndrome (SRUS) is a rare condition in children. We report a case of SRUS in an 8-year old Saudi girl who presented with recurrent rectal bleeding, intermittent mucosal prolapse, and passage of mucus per rectum. Colonoscopy revealed multiple polypoid mass lesions with histopathological features of SRUS. The polypoid variant of SRUS is very rare in children and may be confused with rectal malignant or inflammatory conditions.