Acute hemorrhagic rectal ulcer syndrome: a new clinical entity? Report of 19 cases and review of the literature

Abstract

Purpose: Acute hemorrhagic rectal ulcer syndrome is characterized by sudden onset, painless, and massive hemorrhage from rectal ulcer(s) in patients with serious underlying illnesses. It is a matter of controversy whether acute hemorrhagic rectal ulcer syndrome is a distinct clinical entity. This is the first Asian report on acute hemorrhagic rectal ulcer syndrome to be made outside Japan.

Methods: From January 1989 to December 1999, 8085 patients underwent total colonoscopy at our institution. We retrospectively analyzed the medical records and colonoscopic files. The diagnosis of acute hemorrhagic rectal ulcer syndrome was made by means of the clinical, histologic, and colonoscopic findings.

Results: Among the 8085 patients, 19 patients (11 males; mean age, 71.2 +/- 10.1 years) were diagnosed with acute hemorrhagic rectal ulcer syndrome, which accounted for 2.8 percent of the patients with massive lower gastrointestinal bleeding. The duration from hospitalization to the onset of massive bleeding ranged from 3 to 14 (mean, 9 +/- 3.3) days. Characteristics of colonoscopic appearance were solitary or multiple rectal ulcer(s), with round, circumferential, geographical, or Dieulafoy-like lesions located within a mean of 4.7 cm +/- 1.5 cm from the dentate line. Histopathologically, the lesions appeared as necrosis with denudation of covering epithelium, hemorrhage, and multiple thrombi in the vessels of the mucosa and underlying stroma, which is considered to be similar to stress-related mucosa injury. Successful hemostasis was obtained in 74 percent (14/19) of patients with direct therapeutic maneuvers. Prognosis was largely dependent on accurate diagnosis and management of the underlying disorders.

Conclusions: We assert that acute hemorrhagic rectal ulcer syndrome is a rare but important entity and stress that awareness of this clinical entity should lead to a high index of suspicion resulting in early detection, diagnosis, and appropriate therapy.

Fig. 1.

Colonoscopic findings of acute hemorrhagic rectal ulcer syndrome. A. Patient 8. Multiple round ulcers, adjacent to the dentate line. B. Patient 13. Multiple geographical ulcers, 4 cm proximal to the dentate line. C. Patient 14. Solitary geographical ulcer, 6 cm proximal to the dentate line. D. Patient 10. Solitary round ulcer, 5 cm proximal to the dentate line. E. Patient 18. Multiple circumferential ulcers, 4 cm proximal to the dentate line. F. Patient 15. Solitary Dieulafoy-like ulcer, 4 cm proximal to the dentate line.

Fig. 2.

Histologic findings of acute hemorrhagic rectal ulcer syndrome.(Patient 2). A. Necrosis with focal denudation of covering epithelium, hemorrhage and multiple thrombi in the vessels of the underlying stroma (hematoxylin and eosin (H & E); ×20). B. Multiple thrombi (arrow) in the vessels within mildly inflammatory stroma (H & E; ×40). C. Multiple thrombi (arrow) in the vessels of lamina propria beneath the surface epithelium with focal erosion (H & E; ×40).