P1555 - Acute Hemorrhagic Rectal Ulcer Syndrome: A Raising Phenomenon

Diego Román-Colón, MD¹, Ian Padial-Doble, MD², Natalia Cintrón-Blanco, MD², Pablo Costas-Cáceres, MD^2
1VA Caribbean Healthcare System, San Juan, Puerto Rico; ²University District Hospital, Rio Piedras, Puerto Rico

Introduction: Rectal ulcers with massive hemorrhage have been recognized as an emerging clinical entity. Acute hemorrhagic rectal ulcer syndrome (AHRUS) was first described in Asia and is a rare cause of sudden massive gastrointestinal bleeding. It should be considered in critically ill patients and is characterized by sudden onset, painless, and massive hemorrhage from rectal ulcers. It is usually related to an unfavorable prognosis. We present a case in which awareness and high clinical suspicion enabled early detection and management of the underlying disorders.

Case Description/Methods: A 45-year-old male with past medical history of HIV presented following a pedestrian motor vehicle accident with multiple body trauma. He had a prolonged hospitalization that required craniotomy, bilateral femoral external fixation, acute hemodialysis, and exploratory laparotomy secondary to mesenteric avulsion. Patient presented multiple large episodes of bright red blood per rectum (BRBPR) with associated hypotension, tachycardia, and a drop in hemoglobin 9.1 - > 7 g/dL. Physical examination remarkable for BRBPR with clots and no palpable masses or hemorrhoids during digital rectal exam. Nasogastric tube and gastric lavage against upper etiology. Laboratories revealed normal platelet count, normal coagulation times, and severe hypoalbuminemia. The colonoscope was advanced to the splenic flexure which revealed normal proximal colonic mucosa and a large circumferential ulcerated lesion occupying 75% of lumen at 3 cm from anal verge with a large blood clot that could not be removed despite copious water irrigation. Biopsies were negative for infection or neoplasia. Findings were suggestive of AHRUS. Patient was stabilized with supportive measures and he continued his hospitalization without further bleeding episodes.

Discussion: Advances in technical and pharmacological interventions for the treatment of seriously ill patients may have allowed for the emergence of previously unrecognized clinical entities. Some risk factors that have been associated with AHRUS include critical illness, antithrombotic drug use, acute hemodialysis, or hypoalbuminemia all of which were present in our patient. The use of sucralfate enemas has been beneficial is some case, but our patient’s symptoms resolved with supportive care. Given the emergence of this condition and its unfavorable prognosis, knowledge regarding risk factors enabled high clinical suspicion allowing rapid identification for early colonoscopy, diagnosis, and treatment.


Disclosures:
Diego Román-Colón indicated no relevant financial relationships.
Ian Padial-Doble indicated no relevant financial relationships.
Natalia Cintrón-Blanco indicated no relevant financial relationships.
Pablo Costas-Cáceres indicated no relevant financial relationships.


Diego Román-Colón, MD¹, Ian Padial-Doble, MD², Natalia Cintrón-Blanco, MD², Pablo Costas-Cáceres, MD². P1555 - Acute Hemorrhagic Rectal Ulcer Syndrome: A Raising Phenomenon, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.