Acute Hemorrhagic rectal ulcer syndrome:

Acute Hemorrhagic Rectal Ulcer Syndrome (AHRU) is defined as acute hematochezia with rectal ulcer on endoscopic exam. It accounts for approximately a third of lower GI bleeding in ICU patients and risk factors include elderly patients, bedridden and a history of constipation.

Presentation:

• Bedridden or critically ill patient

• Acute, Painless, Large Volume Hematochezia

• No signs of upper GI bleed

Differential:

• Upper GI Bleed

• Stercoral ulcer

• Ulcerative Colitis

• Radiation Proctitis

Management: Most important part of management is keeping AHRU on the differential. This biggest difference in care of AHRU compared to other etiologies is the decision on bowel prep. For proximal lower GI bleeding a typical oral preparation is needed to allow for appropriate visualization. In AHRU a enema can provide adequate clearance of the rectum and allow for more immediate endoscopic intervention

Treatment:

• Medical treatment includes volume resuscitation, reversal of anticoagulation and appropriate preparation for endoscopy.

• Majority of AHRU cases can be treated endoscopically. On endoscopy typical exam shows large amount of blood in the rectum with visible bleeding or non bleeding ulcers. Majority of ulcerations are seen 3-10cm from the dentate line and can range widely in size and number of ulcerations. A combination of clipping and injection therapy can be used depending on the ulcer.

Outcomes: In the case series reported the best prognostic factor for outcome in patients with AHRU is the patients primary illness. The vast majority of patients that have been identified to have AHRU were critically ill and their survival was most closely attached to primary disease, co-morbidities and ECOG status prior to bleeding event.

Take home points:

• Angiography has not preformed well at identifying AHRU bleeding

• Patients at highest risk are bedridden critically ill patients

• Quick identification of possible AHRU and appropriate choice of bowel prep is important. It can expedite endoscopic evaluation and treatment

• Keep it on the differential for any critically ill patient with large volume painless hematochezia!

Citations:

Jung JH, Kim JW, Lee HW, Park MY, Paik WH, Bae WK, Kim NH, Kim KA, Lee JS. Acute hemorrhagic rectal ulcer syndrome: Comparison with non-hemorrhagic rectal ulcer lower gastrointestinal bleeding. J Dig Dis. 2017 Sep;18(9):521-528. doi: 10.1111/1751-2980.12513. PMID: 28753222.

Sugawa, Choichi PhD, MD∗; Culver, Ashley MD; Diebel, Mark MD; McLeod, Jennifer S. MD; Lucas, Charles E. MD Acute hemorrhagic rectal ulcer: Experience in 11 patients at an urban acute care center in the USA, Medicine: May 2020 - Volume 99 - Issue 18 - p e19836 doi: 10.1097/MD.0000000000019836

Tseng CA, Chen LT, Tsai KB, et al. Acute hemorrhagic rectal ulcer syndrome: a new clinical entity? Report of 19 cases and review of the literature. Dis Colon Rectum. 2004;47(6):895-905. doi:10.1007/s10350-004-0531-1