Abstract
BACKGROUND : Acute hemorrhagic rectal ulcer (AHRU) is an important etiology of lower gastrointestinal bleeding. The clinical and endoscopic features of AHRU have been increasingly reported, especially in Japan. To our knowledge, the clinical characteristics of AHRU based on endoscopic ulcerative patterns have not yet been reported. The aim of this study was to elucidate the clinicoendoscopic features of AHRU and clarify the clinical characteristics based on the ulcerative form classified by endoscopic findings. METHODS : We enrolled 23 patients diagnosed with AHRU on the basis of colonoscopic findings in our hospital. The following were reviewed retrospectively : (1) The background of primary disease and ADL ; (2) usage history of three drugs (NSAIDs, antiplatelet drugs, and steroids) ; (3) endoscopic features of AHRU ; (4) details of the hemostasis and clinical course after endoscopy ; (5) and clinical characteristics based on the ulcerative form classified by endoscopic findings. Fifteen (65.2%) patients underwent blood transfusion (average amount, 7.1 units). Eleven patients (47.8%) were in hypovolemic shock at the time of admission. Hypoalbuminemia was present, with an average albumin level of 2.4 g/dl. In all cases, the chief complaint was fresh hematochezia, moreover painless in nineteen all patients with communication. RESULTS : Most patients were bedridden. A significant proportion of patients suffered from diabetes mellitus (30.4%) as well as other comorbidities such as cerebrovascular disease, orthopedic disease, and cardiovascular disease. Usage of antiplatelet drugs, NSAIDs, and steroids was common, with 9 (39.1%), 5 (21.7%), and 10 patients (43.5%), respectively, using them. NSAIDs were administered as oral formulations in 4 patients and as suppositories in 1. Endoscopic hemostasis was performed in 12 patients (52.2%). Both hypertonic saline-epinephrine administration and clipping were the most frequently performed procedures to achieve hemostasis. Eight patients showed rebleeding after endoscopy, but repeat endoscopic intervention stopped the bleeding in all cases. The ulcerative forms were endoscopically classified into 4 types : Dieulafoy-like type (n = 5, 21.7%), irregular type (n = 12, 52.2%), nearly round type (n = 4, 17.4%), and circumferential type (n = 2, 8.7%). In this study, patients with Dieulafoy-like type had the worst clinical course ; these patients needed the most blood transfusions (80%) and experienced the most frequent rebleeding (80%) after endoscopy. CONCLUSIONS : Successful hemostasis was ultimately possible in all patients ; therefore, AHRU is considered to be a serious disease but has a relatively good prognosis with appropriate therapy. Because Dieulafoy-like type ulcers have the highest risk of major bleeding and highest rate of rebleeding after hemostasis, additional attention and care may be needed to achieve hemostasis in patients with this type.
