VA Caribbean Healthcare System San Juan, PR, United States
Gian Rodriguez-Franco, MD, Andres Rabell-Bernal, MD, Diego Roman-Colon, MD, Roberto Rodriguez-Ramos, MD, Jaime Martinez-Souss, MD, FACG VA Caribbean Healthcare System, San Juan, Puerto Rico
Introduction: Hematochezia is commonly associated with lower gastrointestinal (GI) bleeding, and less so with brisk upper GI bleeding. Malignant lesions are a known cause of gastrointestinal blood loss, but malignancy-associated GI bleeding is mostly caused by colorectal cancer. In rare cases, prostate cancer can mimic gastrointestinal cancer when extensive locoregional disease is present.
Case Description/Methods: An 84-year-old man presented to the ER with complaints of intermittent hematochezia for the past two weeks. Associated symptoms included general malaise and dyspnea on exertion which began three weeks prior to arrival. On examination he has a soft, depressible abdomen and rectal exam is significant for an enlarged prostate and bright red blood per rectum. Laboratories exhibited a hemoglobin level of 8.7g/dL, almost 3 grams lower than his baseline. Chemistry panel was unremarkable. A clinical diagnosis of gastrointestinal hemorrhage was made. The GI service was consulted, and a colonoscopy was performed which revealed a large ulcerated mass at the rectum. No other bleeding stigmata was found. Tissue biopsies were consistent with a poorly differentiated prostate adenocarcinoma, likely representing a contiguous spread to the rectum. MRI of pelvis was remarkable for a marked interval increase of prostate gland since prior studies abutting the anterior rectal wall. Additional history revealed castration-resistant prostate adenocarcinoma diagnosed 3 years earlier, treated with medical therapy leuprolide and bicalutamide. Radiation had been offered multiple times since diagnosis, but patient had refused. Hematochezia persisted and at this point, he agreed with radiotherapy. Due to the high likelihood that radiation could cause fistula formation or perforation, a diverting loop colostomy was performed before beginning therapy. Hematochezia has resolved since.
Discussion: This case illustrates a rare presentation of high-grade prostate cancer. Although hematochezia secondary to locoregional prostate cancer extension is unusual, it should be in the differential when evaluating a patient with undertreated prostate cancer. Careful clinical assessment is important in patients presenting minimal bright red blood per rectum which could be mistaken for hemorrhoids, anal fissures or other etiologies. This is a time-sensitive condition which has the potential to be dismissed for something less serious.
Figure: A: Colonoscopic visualization of a large ulcerated mass at the rectum. B: MRI of pelvis with an enlarged prostate measuring 6.7cm x 6.2cm x 8.9cm. The gland abuts the anterior rectal wall with loss of the anterior serosal surface.
Disclosures: Gian Rodriguez-Franco indicated no relevant financial relationships. Andres Rabell-Bernal indicated no relevant financial relationships. Diego Roman-Colon indicated no relevant financial relationships. Roberto Rodriguez-Ramos indicated no relevant financial relationships. Jaime Martinez-Souss indicated no relevant financial relationships.
Gian Rodriguez-Franco, MD, Andres Rabell-Bernal, MD, Diego Roman-Colon, MD, Roberto Rodriguez-Ramos, MD, Jaime Martinez-Souss, MD, FACG. P1557 - An Unusual Case of Rectal Bleeding, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.