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Acute hemorrhagic rectal ulcer

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					Acute hemorrhagic rectal ulcer
        (AHRU)

           Ri 李宗育
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
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
• ……..
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
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.
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.
D/D of lower gastrointestinal
bleeding
•   Hemorrhoid
•   Anal fissure
•   Rectal ulcer
•   Diverticular disease
•   Arteriovenous malformation
•   Ulcerative colitis
•   Ischemic colitis
•   Colon or rectal tumors
Low rectal ulcer– various
clinical processes (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)
Low rectal ulcer– various
clinical processes (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.
Low rectal ulcer– various
clinical processes (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.
Clinical characteristics of the patients with
AHRU (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
Clinical characteristics of the patients with
AHRU (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
  Clinical characteristics of the patients with
  AHRU (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
  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)
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
Prognosis of AHRU

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