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. 2022 Nov 22;3(1):e184.
doi: 10.1002/deo2.184. eCollection 2023 Apr.

Factors that affect the development of acute hemorrhagic rectal ulcer syndrome and rebleeding

Natsumi Uehara  1   2 , Kazuaki Inoue  3 , Yuichiro Kuroki  4 , Naoki Miyao  2 , Kenta Iwahashi  5 , Reika Suzuki  2 , Toshiyuki Endo  2 , Kunio Asonuma  2 , Erika Yoshida  2 , Naoko Koshibu  2 , Akihiro Tabuchi  2 , Misako Tohata  2 , Shotaro Hanamura  6 , Kuniyo Gomi  2 , Yorimasa Yamamoto  2 , Masatsugu Nagahama  2
Affiliations

Factors that affect the development of acute hemorrhagic rectal ulcer syndrome and rebleeding

Natsumi Uehara et al. DEN Open. .

Abstract

Objectives: Acute hemorrhagic rectal ulcer syndrome (AHRUS) causes massive bleeding and often recurrent rebleeding from rectal ulcers that form immediately above the dentate line. This study aimed to determine the clinical background and risk factors contributing to rebleeding in patients with AHRUS and the most appropriate method of hemostasis treatment.

Methods: This retrospective study included 93 patients diagnosed with AHRUS at Showa University Fujigaoka Hospital, Japan, between April 2009 and November 2018. Information on clinical background factors, endoscopic findings, and hemostasis was obtained from medical records. The relationship with episodes of rebleeding was analyzed by multivariate logistic regression analysis.

Results: The median age was 79 years, and 84 patients (90%) had a performance status of grade 2 or higher. The patients had multiple background factors, with a median number of 5 per patient. The background factors could be classified into two major factors: those related to arteriosclerosis and those related to delayed wound healing.In the multivariate analysis, significantly more rebleeding occurred in patients with active bleeding during the initial endoscopy (odds ratio 4.88, 95% confidence interval 1.80-14.46, p = 0.003); significantly less rebleeding occurred in patients for whom hemostasis was first performed by clipping (odds ratio 0.30, 95% confidence interval 0.09-0.88, p = 0.035).

Conclusions: In bedridden older individuals with poor general health, multiple combinations of arteriosclerosis-related factors and protracted wound healing factors can induce AHRUS. We strongly recommend performing hemostasis via the clipping method on suspected bleeding points, including active bleeding sites, in AHRUS.

Keywords: endoscopy; hemorrhage; hemostasis; rectum; ulcer.

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Conflict of interest statement

None.

Figures

FIGURE 1
FIGURE 1
Acute hemorrhagic rectal ulcer syndrome (AHRUS) at the Showa University Fujigaoka Hospital from April 2009 to October 2018. (a) Among the diagnoses based on the 611 emergency colonoscopies for lower gastrointestinal bleeding, 136 (22%) were AHRUS, the second most common cause of bleeding. (b) Annual trends in the number of AHRUS patients; although there are variations, the trend was broadly increasing. Abbreviation: OGIB, obscure gastrointestinal bleeding
FIGURE 2
FIGURE 2
Case endoscopic photographs of lesion morphology of acute hemorrhagic rectal ulcer syndrome. (a) A case of active bleeding. (b) A case of an ulcer floor‐forming lesion. (c) A case of a Dieulafoy lesion
FIGURE 3
FIGURE 3
The number of rebleeding episodes per case. Of the 93 cases, 31 (33%) experienced rebleeding episodes more than once
FIGURE 4
FIGURE 4
Patient prevalence for each background factor
FIGURE 5
FIGURE 5
Flowchart of the result. Abbreviations: AHRUS, Acute hemorrhagic rectal ulcer syndrome; APC, argon plasma coagulation; CLIP, clipping; EBL, endoscopic band ligation; EC, electrocoagulation
FIGURE 6
FIGURE 6
Examples of endoscopic photographs of cases of acute hemorrhagic rectal ulcer syndrome. (a) A case of a Dieulafoy lesion with multiple exposed vessels. (b) A case in which rebleeding occurred 14 times; several ulcer scars (arrows) are visible around the new ulcer
See this image and copyright information in PMC

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