S3593 A Unique Case of Life-Threatening Anorectal Bleeding Not Amenable to Endoscopic Therapy

Introduction: Anorectal bleeding accounts for a great number of patients presenting with acute hematochezia, with a majority of cases attributed to anal fissures or hemorrhoids. We describe a case of a life-threatening anorectal bleed from a large rectal ulcer not amenable to endoscopic therapy. The ulcer exposed a pulsatile vessel below the dentate line, ultimately requiring surgical consultation for exam under anesthesia and oversewing. Case Description/Methods: An 87-year-old man was admitted to the hospital for the second time in 3 weeks for acute painless hematochezia and symptomatic anemia. A colonoscopy done weeks prior revealed a large circumferential rectal ulcer without high risk stigmata. Biopsies of the ulcer were performed and revealed reactive changes without dysplasia. At that time, bleeding had ceased spontaneously and he was initiated on treatment for stercoral ulceration. Given his overall poor prognosis in setting of refractory metastatic GIST, patient pursued home hospice until returning for this presentation. On physical exam, he was frailwith limited mobility and his underwear was soiled with frank blood. His hemoglobin had decreased by 2 points from his baseline. While patient wished to remain on home hospice, he expressed clear desire to receive focused care for his acute hematochezia. Unsedated flexible sigmoidoscopy was pursued, noting diffuse and circumferential rectal ulceration with active bleeding emanating from a visible vessel along the dentate line. Retroflexion was not pursued given severity of rectal ulceration and perforation risk. Suctioning up of blood with inadvertent suctioning up of mucosa in this area elicited patient discomfort, confirming a sensate area of the anal verge. Because of the location of his bleeding site, endoscopic management was not pursued. After an interdisciplinary discussion regarding goals of care, surgery successfully ligated the bleeding vessel at bedside with local anesthesia. Patient was monitored post procedure in the hospital, continued on a bowel regimen, and able to return to home hospice. Discussion: This case highlights an unusual instance of a life-threatening anorectal bleed necessitating surgical intervention given location along the dentate line. The patient’s hospice status also highlights the nuanced complexity regarding goals of care in the setting of immediately reversible acute GI bleeding and the need for a multidisciplinary approach to optimize patient care.Figure 1.: Pulsating Vessel.