Content uploaded by Li-Tzong Chen
Author content
All content in this area was uploaded by Li-Tzong Chen
Content may be subject to copyright.
A preview of the PDF is not available
Acute Hemorrhagic Rectal Ulcer Syndrome: A New Clinical Entity? Report of 19 Cases and Review of the Literature
Abstract and Figures
Acute hemorrhagic rectal ulcer syndrome is characterized by sudden onset, painless, and massive hemorrhage from rectal ulcer(s) in patients with serious underlying illnesses. It is a matter of controversy whether acute hemorrhagic rectal ulcer syndrome is a distinct clinical entity. This is the first Asian report on acute hemorrhagic rectal ulcer syndrome to be made outside Japan.
From January 1989 to December 1999, 8085 patients underwent total colonoscopy at our institution. We retrospectively analyzed the medical records and colonoscopic files. The diagnosis of acute hemorrhagic rectal ulcer syndrome was made by means of the clinical, histologic, and colonoscopic findings.
Among the 8085 patients, 19 patients (11 males; mean age, 71.2 +/- 10.1 years) were diagnosed with acute hemorrhagic rectal ulcer syndrome, which accounted for 2.8 percent of the patients with massive lower gastrointestinal bleeding. The duration from hospitalization to the onset of massive bleeding ranged from 3 to 14 (mean, 9 +/- 3.3) days. Characteristics of colonoscopic appearance were solitary or multiple rectal ulcer(s), with round, circumferential, geographical, or Dieulafoy-like lesions located within a mean of 4.7 cm +/- 1.5 cm from the dentate line. Histopathologically, the lesions appeared as necrosis with denudation of covering epithelium, hemorrhage, and multiple thrombi in the vessels of the mucosa and underlying stroma, which is considered to be similar to stress-related mucosa injury. Successful hemostasis was obtained in 74 percent (14/19) of patients with direct therapeutic maneuvers. Prognosis was largely dependent on accurate diagnosis and management of the underlying disorders.
We assert that acute hemorrhagic rectal ulcer syndrome is a rare but important entity and stress that awareness of this clinical entity should lead to a high index of suspicion resulting in early detection, diagnosis, and appropriate therapy.
Figures - uploaded by Li-Tzong Chen
Author content
All figure content in this area was uploaded by Li-Tzong Chen
Content may be subject to copyright.
... In the reported literature, as many as 60% of patients with AHRU have died, although in most cases the cause of death has been attributed to comorbidities and not the bleeding itself. [3][4][5]9] Patients with AHRU usually require transfusions, highlighting the importance of prompt diagnosis and management. [2][3][4] Endoscopic treatment is often selected as the initial treatment modality. ...
... The AHRU are commonly located 1 to 7 cm from the dentate line and occasionally at the dentate line. [3,5,9] Due to the limited space and the close distance to the anus, endoscopic hemostasis can be challenging when the bleeding site is close to the dentate line. When endoscopic treatment is not available or failed to achieve sufficient hemostasis, an alternative treatment modality is needed. ...
... Surgical hemostasis with trans-anal suture ligation is a commonly used option. [4,5,9] Trans-anal suture ligation often successfully controls the bleeding, but limited orifice and identification of the bleeding vessel may be difficult and result in insufficient hemostasis. [3] One other treatment option is trans-arterial embolization; [9] however, patients with AHRU are generally elderly and diagnosed with severe underlying conditions such as renal failure. ...
Rationale:
Acute hemorrhagic rectal ulcer (AHRU) is a relatively rare condition characterized by sudden onset, painlessness, and massive hematochezia in patients with severe underlying conditions. When AHRU is encountered, they can often be successfully controlled endoscopically, though recurrent bleeding is common and an alternative treatment must be sought if initial endoscopic treatment fails. We report 2 cases of AHRU which were successfully treated with Vaseline gauze packing after the failure of endoscopic hemostasis.
Patient concerns:
The first patient was an 88-year-old female that visited our emergency department with hematochezia. She was immobilized because of a left pelvic bone fracture resulting from a slip-down. The initial endoscopy showed fresh blood in her rectum with diffuse ulceration near the dentate line but no active bleeding. However, Massive hematochezia has recurred during conservation. A second patient, an 86-year-old female, debilitated because of schizophrenia, dementia, and past subdural hemorrhage, visited our emergency department, also with massive hematochezia. Her initial endoscopy showed deep ulceration near the dentate line. After admission, she experienced massive hematochezia from an AHRU with an exposed vessel but endoscopic hemostasis failed to control bleeding.
Diagnoses:
Both patients were diagnosed as AHRU based on the endoscopic findings.
Interventions:
In both cases, Vaseline gauze packing was performed for bleeding control.
Outcomes:
After Vaseline gauze packing, no further bleeding occurred and follow-up endoscopy showed definitive improvement of ulcers.
Lessons:
Based on these cases, we suggest that Vaseline gauze packing may be the alternative treatment for the AHRU which is located near the dentate line when endoscopic hemostasis is difficult or failed. Although further research is needed, Vaseline gauze packing has several potential advantages for the treatment of AHRU, especially in cases involving critically ill elderly patients.
... They described four cases who showed cerebral ischemia as the acute onset of painless and massive rectal bleeding [1]. Since then, substantial numbers of case series and clinical studies have been reported in Asian countries [2][3][4][5][6][7][8][9][10][11][12][13], and more recently, some reports have indicated that AHRU also exists in Western countries [14][15][16][17]. Currently, AHRU is recognized to be characterized by sudden onset, painless, massive, and fresh rectal bleeding, which frequently occurs in elderly patients with serious complications [6,9,12]. ...
... With an aging population, the incidence of AHRU seems to be increasing in Japan. Although previous studies from other areas reported that AHRU accounted for 2.8-8% of the causes of lower gastrointestinal bleeding (LGIB) [2,6,15], we have recently reported that AHRU accounts for 18.6% of LGIB in Akita prefecture in Japan [18], which is the region with the fastest-aging population in the country [19,20]. A similar phenomenon will be reproduced in other parts of Japan and other countries that are facing an aging society. ...
... On the other hand, there were no significant differences in sex or medication between the two groups. Consequently, the AHRU group showed higher scores in all three scoring systems, with a highly significant difference (all p < 0.0001) in comparison to the non-AHRU group (CHAMPS: 2.5 (2,4) ...
Acute hemorrhagic rectal ulcer (AHRU) is a relatively rare disease that can lead to massive hematochezia. Although AHRU is a potentially life-threatening disease, its characteristics and clinical course are not fully understood. In this study, the clinical features were compared between AHRU and lower gastrointestinal bleeding (LGIB) from other causes (non-AHRU). Then, risk factors for all-cause in-hospital mortality in patients with AHRU were identified. A total of 387 consecutive adult patients with LGIB who were managed at two tertiary academic hospitals in Akita prefecture in Japan were retrospectively enrolled. Subjects were divided into AHRU and non-AHRU groups according to the source of bleeding. Regression analyses were used to investigate significant associations, and the results were expressed as odds ratios (ORs) and 95% confidence intervals (CIs). AHRU was found as the bleeding source in 72 (18.6%) of the patients. In comparison to non-AHRU, having AHRU was significantly associated with in-hospital onset, age > 65 years, and systolic blood pressure < 90 mmHg. The AHRU group had a significantly higher in-hospital mortality rate in comparison to the non-AHRU group (18.0% vs. 8.3, p = 0.02), and hypoalbuminemia (<2.5 g/dL) was significantly associated with in-hospital mortality in the AHRU group (OR, 4.04; 95%CI, 1.11–14.9; p = 0.03). AHRU accounts for a substantial portion (18.6%) of LGIB in our area, where the aging rate is the highest in Japan. Since AHRU is a potentially life-threatening disease that requires urgent identification and management, further studies to identify robust risk factors associated with serious clinical outcomes are required.
... Several diagnostic criteria have been developed by studies such as 1) abrupt massive painless rectal bleeding, 2) serious comorbidities as mentioned above, 3) colonoscopy finding of ulceration with stigmata of bleed, 4) no history of non-steroidal anti-inflammatory drug, and 5) absence of upper GI tract bleed with upper endoscopy [5]. All of these criteria were fulfilled by our patient. ...
... All of these criteria were fulfilled by our patient. It is characterized histopathologically by necrosis with striping of epithelium with multiple thrombi in the vessel findings [5]. ...
... However, the clinical setup is considerably diverse, and caution is needed. The stercoral lesions relate to serious constipation and the stool is very hard at the edge of the lesion [5]. ...
Acute Hemorrhagic Rectal Ulcer Syndrome (AHRUS) is a known and potentially overlooked cause of severe gastrointestinal bleeding in patients with critical illness. It presents as a sudden and brisk painless bleed. It is common among elderly patients who have chronic conditions such as coronary artery diseases associated with the use of anti-platelets, diabetes mellitus, hypoalbuminemia, liver diseases, sepsis, stroke, and chronic renal failure on hemodialysis. AHRUS could result in fatal gastrointestinal hemorrhage. Here, we report a case of acute hemorrhagic rectal ulcer with the above-mentioned risk factors and make the argument that AHRUS should be an important differential in a similar population presenting with a gastrointestinal bleed.
... It has been reported that the rebleeding rate of AHRU ranges from 24.2% to 59.4% (4,(7)(8)(9), and the average time from the initial hemostasis to rebleeding is 6 to 9 days (1,8,9,13). In our present study, the rebleeding rate was 23%, and the average time to rebleeding was 5.2 days, which was almost the same as previously reported results. ...
... Active bleeding or exposed vessels in the AHRU are indications for hemostasis. There are various reports on the efficacy of endoscopic hemostatic methods, such as clipping, hypertonic saline epinephrine (HSE) injection (20), and the use of a heater probe, radiofrequency, and endoscopic band ligation (EBL) (4,9,10,13), but the rate of rebleeding does not significantly differ among these methods (4,8,9). However, in the present study, the use of monopolar hemostatic forceps was suggested to be associated with rebleeding. ...
Objective Acute hemorrhagic rectal ulcer (AHRU) is characterized by sudden, painless, and massive bleeding from rectal ulcers. To date, few studies have analyzed the risk factors for AHRU rebleeding. In this study, we clarified the risk factors of rebleeding after initial hemostasis of AHRU through a multicenter study. Methods A total of 149 patients diagnosed with AHRU between January 2015 and May 2020 at 3 medical centers were enrolled. We retrospectively investigated the following factors: age, sex, body mass index (BMI), performance status (PS), Charlson comorbidity index (CCI), comorbidities, medications, laboratory examinations, endoscopic findings, view of the entire rectum on endoscopy, hemostasis method, blood transfusion history, shock, instructions for posture change after initial hemostasis, and clinical course. Results Rebleeding was observed in 35 (23%) of 149 patients. A multivariate analysis showed that significant factors for rebleeding were PS 4 [odds ratio (OR), 5.23; 95% confidence interval (CI)], 1.97-13.9; p=0.001], a blood transfusion history (OR, 3.66; 95% CI, 1.41-9.51; p=0.008), low an estimated glomerular filtration rate (eGFR) levels (OR, 0.98; 95% CI, 0.97-0.99; p=0.001), poor view of the whole rectum on endoscopy (OR, 0.33; 95% CI, 0.12-0.90; p=0.030), and use of monopolar hemostatic forceps (OR, 4.89; 95% CI, 1.37-17.4; p=0.014). Conclusion Factors associated with rebleeding of AHRU were a poor PS (PS4), blood transfusion, a low eGFR, poor view of the whole rectum on endoscopy, and the use of monopolar hemostatic forceps.
... 1 Histological findings are necrosis, loss of epithelium and thrombosed vessels, similar to stress-induced ulcers in the upper gastrointestinal tract and may share a pathophysiology. 4 In Case 1, a faecal management system may have contributed. While the recommended balloon volume (45 mL) should not be significant given the rectum holds a greater stool volume, prolonged low pressure may ulcerate. ...
... 1,3 While angiographic embolization is reported, some suggest it is associated with a higher rate of rebleeding and mortality; thus AHRU should be differentiated early from more common causes of rectal bleeding in ambulatory patients such as diverticular bleeding where angiography is often first-line. 4 While endoscopic haemostasis is initially successful, up to 50% will bleed again. 2,3 In one study, the only statistically significant risk factor for recurrent bleeding was four or more comorbidities. ...
... Older individuals are more likely to be infected with COVID-19 for various reasons [4], and patients with severe COVID-19 often need to be admitted to the intensive care unit (ICU) for treatment. According to Lin Chengkuan, acute rectal ulcer bleeding is an important cause of severe haematochezia among patients in the ICU (occurring in approximately 1% of patients in the ICU) [5], and is characterised by painless and massive haematochezia caused by solitary or multiple rectal ulcers, usually ranging from 3-10 cm above the dentate line, for which the pathogenesis is currently unclear [6]. To the best of our knowledge, duodenal and rectal ulcer bleeding occurring successively during the treatment of severe COVID-19 in older adults has not previously been reported. ...
Background
In the early stages of the coronavirus disease 2019 (COVID-19) outbreak, the most widely recognised symptoms of the disease were fever, cough, shortness of breath, myalgia, and fatigue. However, in addition to these symptoms, COVID-19 can cause systemic symptoms outside the lungs. Older patients with severe COVID-19 often require admission to the intensive care unit (ICU). Acute rectal ulcer bleeding, characterised by painless, profuse haematochezia, caused by solitary or multiple rectal ulcers, is one of the main causes of severe haematochezia in patients with COVID-19 in the ICU. However, recurrent duodenal ulcer bleeding followed by rectal ulcer bleeding has not previously been reported in older patients during ICU treatment for severe COVID-19.
Cases presentation
Herein, we report the case of an 81-year-old woman admitted to the emergency department due to severe COVID-19 and transferred to the ICU 2 days later for treatment. During treatment in the ICU, the patient developed recurrent duodenal ulcer bleeding and underwent endoscopic electrocoagulation haemostasis and gastroduodenal artery embolisation. However, the night after the final haemostatic operation, due to rectal ulcer bleeding, the patient discharged bloody stools intermittently, which was effectively controlled using endoscopic electrocoagulation, topical medication, blood transfusion, and haemostatic drugs.
Conclusions
To the best of our knowledge, this is the first report of duodenal ulcer bleeding followed by rectal ulcer bleeding in an older patient with severe COVID-19 infection. This report creates awareness for clinicians about the multiple and complex gastrointestinal symptoms that may occur during COVID-19 treatment.
... It was first reported by Kono et al. in 1980. 1 Hirooka established the clinical entity of AHRUS based on his experience gained from treating 10 patients in 1984. 2 This disease is characterized by the sudden onset of painless but extensive bleeding from rectal ulcers located at the distal rectum, directly above the dentate line, in patients suffering from severe comorbidities. 3 There have been many reports of AHRUS in Japan 3-6 and some recent reports from other Asian countries. [7][8][9] Rectal bleeding from a Dieulafoy lesion has been reported in studies from western countries. 10,11 A significant degree of variability exists in the number of reported AHRUS cases worldwide; these discrepancies may depend on how widely this clinical entity is recognized. ...
Objectives:
Acute hemorrhagic rectal ulcer syndrome (AHRUS) causes massive bleeding and often recurrent rebleeding from rectal ulcers that form immediately above the dentate line. This study aimed to determine the clinical background and risk factors contributing to rebleeding in patients with AHRUS and the most appropriate method of hemostasis treatment.
Methods:
This retrospective study included 93 patients diagnosed with AHRUS at Showa University Fujigaoka Hospital, Japan, between April 2009 and November 2018. Information on clinical background factors, endoscopic findings, and hemostasis was obtained from medical records. The relationship with episodes of rebleeding was analyzed by multivariate logistic regression analysis.
Results:
The median age was 79 years, and 84 patients (90%) had a performance status of grade 2 or higher. The patients had multiple background factors, with a median number of 5 per patient. The background factors could be classified into two major factors: those related to arteriosclerosis and those related to delayed wound healing.In the multivariate analysis, significantly more rebleeding occurred in patients with active bleeding during the initial endoscopy (odds ratio 4.88, 95% confidence interval 1.80-14.46, p = 0.003); significantly less rebleeding occurred in patients for whom hemostasis was first performed by clipping (odds ratio 0.30, 95% confidence interval 0.09-0.88, p = 0.035).
Conclusions:
In bedridden older individuals with poor general health, multiple combinations of arteriosclerosis-related factors and protracted wound healing factors can induce AHRUS. We strongly recommend performing hemostasis via the clipping method on suspected bleeding points, including active bleeding sites, in AHRUS.
We investigated the relationship between the endoscopic findings and clinical features in 31 cases of acute hemorrhagic rectal ulcer (AHRU), including 5 cases of rectal exposed vessels without obvious ulcerations. Irregular-shaped ulcers were found in 6 of 13 patients with cerebrovascular diseases. Round-shaped ulcers were seen in 4 of 5 patients with liver disorder and in all of 4 patients after laparotomy. In 5 of 7 patients with renal failure, ulcers were observed on the anterior wall of the lower rectum. However, many cases did not show the difinite relationship between the endoscopical findings and backgrounds of patients. In conclusion, AHRU should be regarded as a syndrome caused by various factors. Close examination on endoscopical findings and backgrounds of each patient is necessary to clarify the pathogenesis of AHRU.
A case of stercoral ulceration with perforation in a colostomy patient is presented, and the literature of stercoral ulcers is reviewed. Significant features of this illness include preceding history of constipation, its presentation as an acute abdomen, radiologic signs of a perforated viscus, and a distinctive histologic picture. Treatment of choice is surgery with exteriorization and colostomy. The condition is rate and has a high mortality, although preoperative diagnosis may play a role in greater survival.
Acute ischemic proctitis is a rare clinical entity caused by vascular insufficiency of the major or collateral circulation to the rectum. It usually occurs following aortic or aortoiliac operations. Six patients with acute ischemic proctitis are presented; four cases occurred after direct arterial interruption, one after accidental embolization of the blood supply to the rectum, and one from tumor edema. Bloody diarrhea was the most common symptom. Loss of anal sphincter tone was also an early sign in three patients. The diagnosis of ischemia was made by mucosal appearance on proctosigmoidoscopy and is differentiated from infectious proctitis by stool culture. Superficial mucosal ischemia was treated without surgery, but deeper levels of necrosis required laparotomy and Hartmann's resection. Rectal excision was not necessary. Four patients survived the ischemic event.
Gastrointestinal haemorrhage after burn injury remains a potentially lethal problem. A retrospective review of 3852 burn patients over 15 years revealed an incidence of gastrointestinal haemorrhage of 2.2 per cent and a mortality of 0.16 per cent. This low incidence of haemorrhage and mortality can be directly related to an aggressive prophylactic treatment with antacid and titration of the gastric pH to 5.5 or above. With this aggressive management programme, few operative procedures were required. A review of autopsy data showed that the site of haemorrhage was distributed throughout the gastrointestinal tract with the predominant site being the stomach.
Acute ischemic proctitis is a rare clinical entity caused by vascular insufficiency of the major or collateral circulation to the rectum. It usually occurs following aortic or aortoiliac operations. Six patients with acute ischemic proctitis are presented; four cases occurred after direct arterial interruption, one after accidental embolization of the blood supply to the rectum, and one from tumor edema. Bloody diarrhea was the most common symptom. Loss of anal sphincter tone was also an early sign in three patients. The diagnosis of ischemia was made by mucosal appearance on proctosigmoidoscopy and is differentiated from infectious proctitis by stool culture. Superficial mucosal ischemia was treated without surgery, but deeper levels of necrosis required laparotomy and Hartmann's resection. Rectal excision was not necessary. Four patients survived the ischemic event.
A retrospective study of 80 patients with biopsy-proven solitary rectal ulcer (SRU) was conducted to review its clinical spectrum. The median follow-up was 25 months. The female-to-male ratio was 1.4:1.0, and the mean age was 48.7 years (range, 14-76 years). Principal symptoms were bowel disturbances (74 percent) and rectal bleeding (56 percent). Twenty-one patients (26 percent) were asymptomatic and required no treatment. A previous "wrong" diagnosis was made in 25 percent. Rectal prolapse was identified in 28 percent (full-thickness, 15 percent; mucosal, 13 percent). The macroscopic appearance of the lesion seen in SRU varied widely and included polypoid lesions in 44 percent (the predominant finding in the asymptomatic group), ulcerated lesions in 29 percent (always symptomatic), and edematous, nonulcerated, hyperemic mucosa in 27 percent. Anorectal manometry provided little helpful information in the patients in whom it was performed. Management by bulk laxatives and bowel retraining led to symptomatic improvement in 19 percent of cases. In 29 percent of cases, symptoms persisted despite endoscopic healing of the lesion. Intractability of symptoms led to surgery in only 27 (34 percent) patients. Depending on the presence or absence of rectal prolapse, rectopexy or a conservative local procedure (such as local excision), respectively, appeared to be the optimal surgical treatment. The polypoid variety tended to respond to therapy more favorably than non-polypoid varieties. Thus, the macroscopic appearance of SRU has a significant bearing on the clinical course, and most cases do not require surgery.