DESCRIPTION

A 38-year-old man who had been an inactive hepatitis B virus carrier presented with jaundice (duration 5 days). He was diagnosed as having fulminant hepatitis B and was admitted to the intensive care unit for continuous haemodiafiltration with plasma exchange. By 4 days later, he was in shock with sudden onset, painless, massive exsanguinating haematochezia requiring 1200 ml of red blood cell transfusion. A CT scan showed an extravasation in the rectum (fig 1, arrow). Subsequent colonoscopy disclosed a huge round rectal ulcer with an exposed vessel in the lower rectum (fig 2), consistent with acute haemorrhagic rectal ulcer (AHRU), which was treated with endoscopic clipping. The patient died from liver failure despite the intensive management and control of the haemorrhage.

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Figure 1

CT scan of the abdomen showing an extravasation in the rectum (arrow).

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Figure 2

Colonoscopy showing an acute haemorrhagic rectal ulcer with an exposed vessel.

AHRU is characterised by sudden onset, and painless and massive haemorrhage from rectal ulcers which frequently occur in patients who are elderly and bedridden with serious illness such as cerebral vascular disease, renal failure, respiratory failure, liver cirrhosis, sepsis and malignancy.1 It has been increasingly recognised as an important clinical entity worldwide.1^,2 Reduction of blood flow to the rectum associated with severe underlying disorder has been presumed for the aetiology. The reported duration from hospitalisation to haematochezia ranged from 3 to 14 days (mean 7.5).1 The endoscopic features are round, geographical, or circumferential ulcer located near the dentate line.1^,3 Haemostasis can be achieved with endoscopic clipping, local injection of haemostatic agents, cauterisation, or transanal suture ligation.1^–3

In conclusion, AHRU should be considered in the differential diagnosis of sudden onset, painless, life-threatening haematochezia of patients who are critically ill, even at a young age. We also emphasise that AHRU can occur earlier than ever expected. Early diagnosis and appropriate haemostasis are critical for the favourable outcome.