Acute hemorrhagic rectal ulcer (AHRU)

1. Acute hemorrhagic rectal ulcer (AHRU) Ri 李宗育

2. Patient Profile (I) • Brief History: The 69 y/o woman with… • 1998/05 Diagnosis of SLE was made • 2006/09 Cardiac echo: severe As, moderate MR and TR • 2006/10/18 shortness of breath and bilateral pitting edema…Our ER:CXR: cardiomegaly with hilar congestion and pleural effusion • 10/26 Cath: LV-Ao pressure gradient 30mmHg R’t femoral hematoma => pseudoaneurysm • 10/31 fever with productive cough, WBC and CRP↑CXR: RLL consolidation, U/A: pyuria=> CCU, intubation=> difficult weaning11/23 Tracheostomy…11/27 Op: repair pseudoaneurysm, abx: cefmetazole12/05 Transferred to RCC => weaning failed…12/25 Operation: AVR

3. Patient Profile (II) • 2007/01/05 B/C, S/C, CVP tip: Pseudomonas • 2007/01/10: hemorrhoid bleeding with coffee-ground drainage • 2007/01/16: Try CPAP0 • 2007/1/18: LGI bleeding • 2007/01/19: Rectal ulcer sucrate r • 2007/01/20: Still blood clot in stool NPO*1 day • 2007/01/22: still bloody stool NPO, ID: keep diflucan • 2007/01/23: B/C(01/21): GNB, ID: add ceftriaxone, DC ciproxin • 2007/01/24: GI-rectal ulcer 3 cm in diameter, 5 cm above AV • 2007/01/25: tongue bleeding ENT packing • 2007/01/26: fever, culture, ID: add vanco • ……..

4. Patient Profile (III) • Endoscopic finding: • 2007/01/19 • Scattered erosions were noted at sigmoid colon. Multiple ulcers with erythematous margin were noted at lower rectum. These ulcers were confluent and covered with exudate and fecal material near anal verge. No active bleeding was noted. • Hemorrhagic rectal ulcers; Nonspecific colitis, Sigmoid colon May try sucralfate gel enema

5. Patient Profile (IV) • Endoscopic finding: • 2007/01/24 • Much fresh blood and blood clots were noted from anus to sigmoid colon. Diffuse ulcers with friable mucosa were noted at distal rectum, just above anal verge. There was active oozing. Sucralfate gel was sprayed to this ulcerative mucosa. • Hemorrhagic rectal ulcer, rectum s/p sucralfate spray  Suggest compression with epinephrine-rinsed gauze. Suggest surgical consultation for proctoscopy.

6. D/D of lower gastrointestinal bleeding • LGI bleeding is usually self-limited rather than severe and ongoing. • Self-limited LGI bleeding: 90 percent identified by way of elective assessment • Severe or ongoing hematochezia: 10 percent These patients usually require urgent assessment and resuscitation. • Various techniques—such as angiography,scintigraphy, and emergent colonoscopy —have been used to identify the location and the nature of the bleeding lesion.

7. D/D of lower gastrointestinal bleeding • Hemorrhoid • Anal fissure • Rectal ulcer • Diverticular disease • Arteriovenous malformation • Ulcerative colitis • Ischemic colitis • Colon or rectal tumors

8. Low rectal ulcer– various clinical processse (I) • Stercoral ulcer • Solitary rectal ulcer syndrome • Ischemic rectal ulcer • Radiation-related ulcer, traumatic rectal ulcer • Rectal ulcers secondary to therapy with nonsteroidal compounds • Acute hemorrhagic rectal ulcer (AHRU)

9. Low rectal ulcer– various clinical processse (II) • Stercoral ulcer: developed by pressure necrosis from a fecal mass, which occurs most frequently as an individual lesion in the rectosigmoid colon junction. • Solitary rectal ulcer syndrome: • young adults with a history of constipation, self-digitation, anorrectal prolapse. • fibrous obliteration of the lamina propria with disorientation of muscle fiber. • Erythematous and edematous mucosa.  the surrounding mucosa of AHRU is normal or only slightly hyperemic.

10. Low rectal ulcer– various clinical processse (III) • Ischemic rectal ulcer: frequently experience abdominal pain, but the onset of AHRU is painless. • Rectal ulcer caused by radiation, trauma, or nonsteroidal compounds is distinguishable by history from AHRU.

11. Clinical characteristics of the patients withAHRU (I) • There have been several reports on AHRU in Japan, but in Western countries, there have been just few reports. • Diagnosis: • Clinical symptoms • Endoscopic examination • R/O: • Stool or biopsy cultures were negative • No history of radiation or NSAIDS

12. Clinical characteristics of the patients withAHRU (II) • Clinical features of AHRU are as follows: • Most common in elderly women; • Accompanies serious underlying disorders • Onset is sudden, painless, and accompanied by massive rectal bleeding • Most of the patients are bed-ridden

13. Clinical characteristics of the patients withAHRU (III) • Endoscopic appearances of AHRU are as follows: • Shallow and irregular or circumferential ulcer, which is situated in the terminal rectum immediately proximal to the dentate line, occupying from one third to the entire circumference of the rectum

14. The processes leading to AHRU • The confirmation of these mechanisms remains uncertain. • Histopathologic examination: necrosis with denudation of covering epithelium, hemorrhage, and multiple thrombi in the vessels of the epithelium and underlying stroma identical to those of hemorrhagic necrosis of GI tract in p’t with CV dysfunction, shock or sepsis • Stress induced disturbance of the circulation in the small intramural vessels (secretion of catecholamines or vasoconstrictive gastrointetinal polypeptide)

15. Treatment and Management of AHRU • Cauterization • Injection of pure ethanol seldom • Transanal suture ligation high hemostasis rate • Gauze tamponade  high recurrent bleeding rate • Visceral angiography  high rate of mortality and renewed bleeding

16. Prognosis of AHRU • The prognosis of AHRU was primarily dependent on accurate diagnosis and management of the underlying disorders.

17. References • Journal of Clinical Gastroenterology. 33(3):226-228, September 2001. • Digestive Endoscopy. 16(3):A34, July 2004. • Diseases of the Colon&Rectum. 49(2): 238-243, February 2006 • Diseases of the Colon&Rectum. 47(2): 895-905, May 2004.