P2593 - Acute Hemorrhagic Rectal Ulcer Syndrome: A Known yet Often Overlooked Etiology of Gastrointestinal Bleeding in Chronically Ill Patients

Yasir Rajwana, MD¹, Kosisochukwu Ezeh, MD², Etan B. Spira, MD, FACG^2
1Jersey City Medical Center, Newark, NJ; ²Jersey City Medical Center, Jersey City, NJ

Introduction: Acute Hemorrhagic Rectal Ulcer Syndrome (AHRUS) is an often overlooked etiology of potentially serious gastrointestinal bleeding. It is characterized by painless, abrupt, massive rectal bleeding observed mostly in elderly populations with chronic illnesses or risk factors such as diabetes mellitus, coronary artery diseases, stroke, sepsis, liver failure, hypoalbuminemia and chronic renal failure with hemodialysis, immobility, antithrombotic drug use.

Here we report a case of acute hemorrhagic rectal ulcer with above mentioned risk factors and make the argument that AHRUS should be an important differential in similar population presenting with a gastrointestinal bleed.

Case Description/Methods: A 63 year old male with history of decompensated liver cirrhosis secondary to alcohol use, coronary artery disease and hypertension who presented with a one day history of painless rectal bleed. He had no history of previous GI bleeding. He had been on dual anti platelet therapy for medical management of triple vessel disease deemed inoperable due to advanced liver disease. He had no prior colonoscopy nor upper endoscopy. He had altered mental status but no ascites. Jaundice, positive orthostasis and large blood clot protruding from rectum were seen on physical examination.

Initial laboratory values showed Hgb 12.5g/dl, MCV100.2, HCT 38.4, WBC 9.8, PT 14.4, INR 1.14, PTT 40.3, Albumin 3.5, AST 108, ALT 58, ALP 629. Total bilirubin 4.6, direct bilirubin 3, BUN/Cr 36/2.21, and Sodium 123.Patient continued to have multiple large volume bright red bloody bowel movements Resuscitation measures were initiated and he was admitted to the intensive care unit. He required multiple blood transfusions due to precipitous fall in hemoglobin and hypotension. EGD revealed no active bleeding source. Colonoscopy showed two rectal ulcers with one showing stigmata of recent bleeding. It was subsequently cauterized with gold probe resulting in cessation of further bleeding.

Discussion: AHRUS occurs in elderly, critically ill, and bedridden patients with sudden, severe, painless, rectal bleeding and managed by correction of coagulopathy and by endoscopic hemostasis. Early identification of these risk factors in evaluation of lower GI bleed could make clinicians more aware of the possibility of AHRUS as an important differential diagnosis to consider in elderly populations especially with the risk factors described above besides common causes like diverticulosis as early recognition can lead to timely therapeutic intervention.


Figure: Rectal Ulcer before and after Gold Probe Cauterization


Disclosures:
Yasir Rajwana indicated no relevant financial relationships.
Kosisochukwu Ezeh indicated no relevant financial relationships.
Etan Spira indicated no relevant financial relationships.


Yasir Rajwana, MD¹, Kosisochukwu Ezeh, MD², Etan B. Spira, MD, FACG². P2593 - Acute Hemorrhagic Rectal Ulcer Syndrome: A Known yet Often Overlooked Etiology of Gastrointestinal Bleeding in Chronically Ill Patients, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.