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Hamada N, Maeda R, Suyama A, Yuzurio S, Oda W, Suwaki T. Acute Hemorrhagic Rectal Ulcer Complicated by Cytomegalovirus Enteritis following Steroid Pulse Therapy for Acute Exacerbation of Interstitial Pneumonia. Intern Med 2023; 62:2335-2339. [PMID: 36543211 PMCID: PMC10484779 DOI: 10.2169/internalmedicine.0823-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/10/2022] [Indexed: 12/24/2022] Open
Abstract
We herein report a rare case of acute hemorrhagic rectal ulcer (AHRU) complicated by cytomegalovirus enteritis following steroid pulse therapy for interstitial pneumonia. An 86-year-old woman underwent steroid pulse therapy for interstitial pneumonia. She was bedridden with dyspnea and suddenly developed melena. Colonoscopy revealed AHRU, which did not improve with conservative treatment, but did improve with ganciclovir administration for cytomegalovirus enteritis. This gastrointestinal complication has not received much attention by pulmonologists who perform steroid pulse therapy for interstitial pneumonia. Delayed treatment of this complications can be fatal. Caution should be taken when administering steroid pulse therapy to bedridden patients with interstitial pneumonia.
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Affiliation(s)
- Noboru Hamada
- Department of Respiratory Medicine, Okayama City Hospital, Japan
| | - Ruri Maeda
- Department of Respiratory Medicine, Okayama City Hospital, Japan
| | - Atsuhito Suyama
- Department of Respiratory Medicine, Okayama City Hospital, Japan
| | - Shouta Yuzurio
- Department of Respiratory Medicine, Okayama City Hospital, Japan
| | - Wakako Oda
- Department of Pathology, Okayama City Hospital, Japan
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Fujita M, Manabe N, Murao T, Suehiro M, Tanikawa T, Nakamura J, Ishii K, Monden S, Uji E, Misawa H, Ninomiya T, Sasahira M, Chikaishi M, Yo S, Osawa M, Katsumata R, Ayaki M, Ishii M, Kawamoto H, Shiotani A, Hata J, Haruma K. Differences between patients with inpatient-onset and outpatient-onset acute lower gastrointestinal bleeding: An observational study. J Gastroenterol Hepatol 2023; 38:775-782. [PMID: 36706165 DOI: 10.1111/jgh.16134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/22/2022] [Accepted: 01/25/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIM The clinical severity and course of acute lower gastrointestinal bleeding (ALGIB) are believed to differ between inpatient-onset and outpatient-onset cases, but no reports have investigated these issues in detail. We aimed to evaluate the clinical differences between inpatient-onset and outpatient-onset ALGIB. METHODS Medical records of patients who had undergone emergency colonoscopy for ALGIB were retrospectively reviewed. The severity was evaluated using the NOBLADS score. Patients with obvious ALGIB relapse and/or persistent iron-deficiency anemia after emergency colonoscopy were considered to exhibit a poor clinical course. RESULTS We reviewed 723 patients with ALGIB and divided them into the inpatient-onset cohort (172 patients) and outpatient-onset cohort (551 patients). Compared with the outpatient-onset cohort, the inpatient-onset cohort had a significantly higher proportion of patients with a poor clinical course (51.2% vs 21.6%; P < 0.001) and a significantly higher mean NOBLADS score (3.6 ± 1.1 vs 2.5 ± 1.0; P < 0.001). The most common bleeding source was acute hemorrhagic rectal ulcer (52.3%) in the inpatient-onset cohort and colonic diverticular bleeding (29.4%) in the outpatient-onset cohort. Multivariate analysis showed that a platelet count < 15 × 104 /μL and albumin concentration < 3 g/dL were significantly associated with a poor clinical course in the inpatient-onset cohort. CONCLUSIONS The clinical course was significantly worse in the inpatient-onset cohort than in the outpatient-onset cohort. The bleeding source, clinical characteristics, and clinical course differed between the inpatient-onset and outpatient-onset cohorts. The clinical course in the inpatient-onset cohort may depend on the patient's condition at ALGIB onset.
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Affiliation(s)
- Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Takahisa Murao
- Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan
- Department of Health Care Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Mitsuhiko Suehiro
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Tomohiro Tanikawa
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Jun Nakamura
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Katsunori Ishii
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Syuzo Monden
- Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan
| | - Emiko Uji
- Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan
| | - Hiraku Misawa
- Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan
| | - Takehiro Ninomiya
- Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Momoyo Sasahira
- Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan
| | - Masaya Chikaishi
- Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan
| | - Shogen Yo
- Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan
| | - Motoyasu Osawa
- Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan
| | - Ryo Katsumata
- Department of Health Care Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Maki Ayaki
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Manabu Ishii
- Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Hirofumi Kawamoto
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Akiko Shiotani
- Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan
| | - Jiro Hata
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School Hospital, Kurashiki, Japan
| | - Ken Haruma
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan
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Takahashi Y, Shimodaira Y, Matsuhashi T, Tsuji T, Fukuda S, Sugawara K, Saruta Y, Watanabe K, Iijima K. Nature and Clinical Outcomes of Acute Hemorrhagic Rectal Ulcer. Diagnostics (Basel) 2022; 12:diagnostics12102487. [PMID: 36292176 PMCID: PMC9600341 DOI: 10.3390/diagnostics12102487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/08/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Yasutaka Takahashi
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita 010-8543, Japan
- Department of Gastroenterology, Akita City Hospital, Akita 010-0933, Japan
| | - Yosuke Shimodaira
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita 010-8543, Japan
- Correspondence:
| | - Tamotsu Matsuhashi
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita 010-8543, Japan
| | - Tsuyotoshi Tsuji
- Department of Gastroenterology, Akita City Hospital, Akita 010-0933, Japan
| | - Sho Fukuda
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita 010-8543, Japan
| | - Kae Sugawara
- Department of Gastroenterology, Akita City Hospital, Akita 010-0933, Japan
| | - Youhei Saruta
- Department of Gastroenterology, Akita City Hospital, Akita 010-0933, Japan
| | - Kenta Watanabe
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita 010-8543, Japan
| | - Katsunori Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita 010-8543, Japan
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Hassranah S, Maharajh S, Solomon S, Naraynsingh V. Massive Rectal Hemorrhage From a Stercoral Ulcer. Cureus 2022; 14:e26963. [PMID: 35989792 PMCID: PMC9382688 DOI: 10.7759/cureus.26963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2022] [Indexed: 11/17/2022] Open
Abstract
Massive lower gastrointestinal (GI) bleeding from stercoral ulcers is exceedingly rare. We report a case of a middle-aged man who presented with progressively deteriorating neurologic function with constipation and subsequent massive GI bleeding per rectum. While an uncommon cause of GI bleeding, such patients require rapid resuscitation and timely diagnosis of these ulcers since the usual management of such cases will be futile and harmful due to potentially inappropriate surgical bowel resection.
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Okamoto T, Takasu A, Yoshimoto T, Yamamoto K, Shiratori Y, Ikeya T, Fukuda K. Digital compression for hemostasis in acute hemorrhagic rectal ulcer: a report of 4 cases and review of the literature. Clin J Gastroenterol 2021; 14:796-804. [PMID: 33550538 DOI: 10.1007/s12328-021-01353-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Abstract
Acute hemorrhagic rectal ulcer is a relatively rare cause of lower gastrointestinal bleeding. It most commonly occurs in bedridden elderly patients with multiple comorbidities. While the diagnosis can be confirmed on colonoscopy, achieving hemostasis may be difficult due to the poor visual field resulting from severe bleeding and stool remaining in the rectum, the stiffness of ulcers which may preclude effective clipping, the poor tolerability of patients for the procedure, and high risk of recurrence. Here, we present 4 cases of acute hemorrhagic rectal ulcer, where hemostasis could not be achieved through traditional methods. In each case, the assistant introduced his finger into the rectal lumen and digitally compressed the bleeding vessel under endoscopic guidance. Once hemostasis was achieved, the responsible vessel could be visualized and traditional hemostatic measures were taken. No recurrence was observed in any of the cases during follow-up. This simple maneuver can be applied safely and effectively even by assistants attempting the maneuver for the first time. The technique was effective with the endoscope in retroflexed position and could be combined with gel immersion endoscopy to first identify the location of hemorrhage. We also review the existing literature on acute hemorrhagic rectal ulcers.
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Affiliation(s)
- Takeshi Okamoto
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan.
| | - Ayaka Takasu
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Takaaki Yoshimoto
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Kazuki Yamamoto
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Yasutoshi Shiratori
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Katsuyuki Fukuda
- Department of Gastroenterology, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
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Luo J, Shi X, Lin Y, Cheng N, Shi Y, Wang Y, Wu BQ. Cytomegalovirus Infection in an Adult Patient With Neuromyelitis Optica and Acute Hemorrhagic Rectal Ulcer: Case Report and Literature Review. Front Immunol 2020; 11:1634. [PMID: 32849558 PMCID: PMC7417347 DOI: 10.3389/fimmu.2020.01634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 06/18/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Previous infectious or inflammatory events may be involved in the pathogenesis of neuromyelitis optica (NMO), potentially by triggering an autoimmune response. Cytomegalovirus (CMV)-related NMO (CMV-NMO) is rarely reported. Acute hemorrhagic rectal ulcer (AHRU) is a rare disease with a largely unknown pathogenesis. Herein, we reported a co-NMO and AHRU case associated with CMV infection. In addition, we review previously reported cases of CMV-NMO and CMV-AHRU. Case presentation: A 40-year-old female diagnosed with aquaporin4 (AQP4)-IgG+ NMO and a poor response to high-dose intravenous methylprednisolone and immunoglobulin, followed by three rounds of plasma exchange was transferred to Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. She developed repeated acute lower gastrointestinal hemorrhage from the third day of admission. Abdominal computed tomography angiography (CTA) and interventional angiography did not detect any bleeding vessel. Bedside colonoscopy revealed a large ulcer-like lesion at 10 cm above the anus. Rectal biopsy pathology confirmed a CMV infection on day 23 post-admission, and cerebrospinal fluid (CSF) pathogen gene sequencing detected CMV gene copies on day 25 post-admission. After 2 weeks of treatment with ganciclovir and sodium phosphinate, the patient's lower gastrointestinal bleeding stopped, and her limb muscle strength and visual acuity gradually improved. After 4 weeks of antiviral therapy, colonoscopy showed that the intestinal wall of the original lesion was smooth. Hematoxylin and eosin (HE) staining and immunohistochemistry (IHC) of a biopsy specimen was negative for CMV, her right eye vision was normal, and limb muscle strength had recovered. Serum AQP4-IgG was negative, and lesions on brain magnetic resonance imaging (MRI) manifested shrinkage. Conclusions: The benefits of antiviral therapy remain unclear; however, clinicians should be aware of the possibility of CMV-related NMO, if NMO was refractory to high-dose intravenous methylprednisolone, immunoglobulin, and plasma exchange. Moreover, clinicians should consider the possibility of CMV-related AHRU when recurrent acute lower gastrointestinal bleeding occurs in a patient.
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Affiliation(s)
- Jinmei Luo
- Medical Intensive Care Unit and Division of Respiratory Diseases, Department of Internal Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaowei Shi
- Medical Intensive Care Unit and Division of Respiratory Diseases, Department of Internal Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ying Lin
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Na Cheng
- Department of Pathology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yunfeng Shi
- Medical Intensive Care Unit and Division of Respiratory Diseases, Department of Internal Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yanhong Wang
- Medical Intensive Care Unit and Division of Respiratory Diseases, Department of Internal Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ben-Quan Wu
- Medical Intensive Care Unit and Division of Respiratory Diseases, Department of Internal Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Ben-Quan Wu
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[Rectal bleeding: easy to overcome or still a challenge in proctology?]. Chirurg 2019; 90:640-647. [PMID: 30911796 DOI: 10.1007/s00104-019-0944-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Rectal bleeding is a frequent symptom in proctology. In most cases frequent causes, such as anal fissures and hemorrhoidal disease can be diagnosed and treated using a structured patient history and basic proctological diagnostic assessment; however, it is not uncommon for proctitis to be the reason for rectal bleeding, which necessitates interdisciplinary diagnostics and treatment. In addition to proctitis associated with chronic inflammatory bowel disease, prolapse-induced, radiogenic, ischemic, infectious types and proctitis associated with sexually transmitted diseases represent important differential diagnoses. Moreover, rectal cancer has to be excluded as the cause of rectal bleeding. Finally, with appropriate diligence most causes of rectal bleeding can be securely identified and effectively managed; however, special circumstances can necessitate interdisciplinary diagnostics and management, including conservative, topical, interventional and surgical treatment options.
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