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ORIGINAL ARTICLE
Year : 2014  |  Volume : 34  |  Issue : 1  |  Page : 35-39

Liver cirrhosis is a risk factor of repeat acute hemorrhagic rectal ulcer in intensive care unit patients


Department of Surgery, Division of Colon and Rectal Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China

Date of Submission23-Oct-2013
Date of Decision06-Nov-2013
Date of Acceptance18-Nov-2013
Date of Web Publication26-Mar-2014

Correspondence Address:
Cheng-Wen Hsiao
Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Cheng-gong Road, Taipei 114, Taiwan
Republic of China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1011-4564.129390

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  Abstract 

Background: Acute hemorrhagic rectal ulcer (AHRU) can be found in patients with severe comorbid illness, who are bedridden for a long time. Per anal suturing is a quick and feasible treatment. However, recurrent bleeding occurs frequently after suture ligation of a bleeder and can be life-threatening. However, the risk factor for recurrent bleeding is not well known. Our study tries to clarify the risk factor of repeat AHRU in Intensive Care Unit (ICU) patients. Materials and Methods: From January 2004 to December 2009, the medical records of 32 patients, who were admitted to the ICU of the Tri-Service General Hospital, a tertiary referral center in Taiwan, and who underwent per anal suturing of acute hemorrhagic rectal ulcer were retrospectively reviewed. Results: Of the 96 patients who received emergency treatment for acute massive hematochezia, 32 patients were diagnosed with AHRU. Eight (25%) patients had recurrent bleeding following suture ligation of AHRU and underwent a reoperation; no patient had recurrent bleeding after the second operation. The duration from the first hematochezia attack to surgery (P = 0.04), liver cirrhosis (P = 0.002), and coagulopathy (P = 0.01) were the risk factors of recurrent bleeding after suture ligation of a bleeder. Multivariate logistic regression analysis indicated that liver cirrhosis (OR = 37.77, P = 0.014) was an independent risk factor for recurrent bleeding. Conclusion: AHRU could be a major cause of acute massive hematochezia in patients with severe illness. Our data showed that per anal suturing could quickly and effectively control bleeding. We found that liver cirrhosis was an independent risk factor for recurrent bleeding. Therefore, treatment of a liver cirrhosis patient with AHUR should be more aggressive, such as, early detection and proper suture ligation.

Keywords: Acute hemorrhagic rectal ulcer, liver cirrhosis, recurrent bleeding, rectal bleeding, intensive care unit


How to cite this article:
Chang PK, Kao CH, Wu CC, Lee CC, Lee TY, Jao SW, Hsiao CW. Liver cirrhosis is a risk factor of repeat acute hemorrhagic rectal ulcer in intensive care unit patients. J Med Sci 2014;34:35-9

How to cite this URL:
Chang PK, Kao CH, Wu CC, Lee CC, Lee TY, Jao SW, Hsiao CW. Liver cirrhosis is a risk factor of repeat acute hemorrhagic rectal ulcer in intensive care unit patients. J Med Sci [serial online] 2014 [cited 2019 Dec 15];34:35-9. Available from: http://www.jmedscindmc.com/text.asp?2014/34/1/35/129390


  Introduction Top


The occurrence of major lower gastrointestinal (LGI) hemorrhage in Intensive Care Unit (ICU) patients has been reported to range from 0.15 to 0.94%. [1],[2] A recent report has found that an acute hemorrhagic rectal ulcer (AHRU) is the leading cause (31.6%) of acute LGI bleeding in ICU patients. [3] The characteristics of AHRU are sudden-onset, painless, and massive anal bleeding in bedridden patients with severe underlying disease, as is the case in most patients in the ICU. [4] AHRU can be quickly managed with per anal suture ligation of the bleeder via an anoretractor, [5] and the disease can also be managed with endoscopic hemostasis. Unfortunately, recurrent bleeding occurs frequently, requiring a second suture ligation or a second endoscopy with hemostasis. The risk factors for recurrent bleeding are not well known. We present a retrospective study of 32 ICU patients with severe comorbidities, who have had AHRU. We describe the characteristic of AHRU, the risk factors for re-bleeding, and the outcomes of these patients.


  Materials and Methods Top


Between January 1, 2004, and December 31, 2009, the medical records of patients who developed anorectal bleeding and underwent transanal suture ligation after admission to the ICU of the National Defense Medical Center, a tertiary referral center in Taiwan, were retrospectively reviewed. The patients were restricted to the following criteria:

  1. Acute onset painless hematochezia;
  2. Active bleeder over the distal rectum confirmed by an anoretractor and performance of suture ligation;
  3. Increase in heart rate by > 20 beats per minute; and
  4. Required blood transfusion; the blood transfusion amount was not restricted.


Combined upper gastrointestinal and LGI bleeding was excluded. Patients with hematochezia from hemorrhoids, anal fissures, and recent anal surgery were excluded. No patient had a history of pelvic radiation.

The patients' data were collected, including sex, age, comorbid disease, duration from bleeding to operation, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, coagulopathy (international normalized ratio (INR) >1.5), thrombocytopenia (platelet count <150,000/mm 3 ), approximate blood loss, blood transfusion amount, recurrent bleeding, and clinical outcome.

We analyzed the differences in the potential risk factors for recurrence of acute hemorrhagic rectal ulcer bleeding after suture ligation of the bleeder in patients, by using a t-test and a chi-squared or Fisher's exact test. For risk factors that were significantly associated with recurrence in the bivariate analyses, at P < 0.05, we fitted multivariable logistic regression models to estimate the odds ratios, with 95% confidence intervals for each potential risk factor and the study outcomes. All analyses were performed using the SPSS, version 17.0, for Windows (SPSS, Inc.). The significance level was 5% for all analyses.


  Results Top


Patient general characteristics

Between January 1, 2004 and December 31, 2009, of 96 patients who received emergency management for acute massive hematochezia, 32 patients were diagnosed with AHRU [Table 1]. All 32 patients with AHRU received urgent surgical intervention with transanal suture ligation of the bleeder. Eight (25%) patients had recurrent bleeding and a second operation was performed; no patient had recurrent bleeding after the second operation. The general characteristics of the patients and group comparison result are summarized in [Table 2]. Group 1 was the 'recurrent bleeding' group and group 2 was the 'no recurrent bleeding' group. Most patients were elderly, and the mean age was 74.2 years (range: 34 to 93 years). There were 14 men and 18 women. Fifteen (46.8%) patients had hemodialysis and six (18%) patients had cirrhosis of the liver. Eleven (34%) patients had coagulopathy and 16 (50%) patients had thrombocytopenia. The mean duration from the first hematochezia to surgery was 8.2 hours (range: 3 to 24 hours). Seventeen (53%) patients died during hospitalization due to other clinical diseases. The mean blood transfusion amount was 6.2 units (range: 2 to 16 units) and the mean blood loss was 1212 ml (range: 200 to 3500 ml). The duration from the first hematochezia attack to surgery (P = 0.04), liver cirrhosis (P = 0.002), and coagulopathy (P = 0.01) were risk factors for recurrent bleeding after suture ligation of the bleeder. Multivariate logistic regression analysis indicated that liver cirrhosis (OR = 37.77, P = 0.014) was an independent risk factor for recurrent bleeding.
Table 1: Clinical Characteristics of the Patients

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Table 2: Group comparison

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Diagnosis, management, and outcome of acute hemorrhagic rectal ulcer

In our hospital, if patients have massive hematochezia, the colorectal surgeon is consulted. The diagnosis flow chart is shown in [Figure 1]. If the blood is found to be fresh and not mixed with stool by digital rectal examination (DRE), anorectal bleeding is highly suspected. An emergency ano retractor exam is performed with the patient in the lateral decubital position. If dark reddish blood or blood mixed with stool is found by DRE, a bleeding source from the proximal colon or upper gastrointestinal tract is highly suspected. Angiography, computed tomography angiography (CTA) or colonoscopy will be performed depending on the patient's condition and the attending doctor's decision. In our study, 26 patients presented with massive bleeding with fresh blood, not mixed with stool, and were quickly diagnosed with AHRU by anoretractor. Another five patients were diagnosed using colonoscopy, and only one patient was diagnosed using angiography.
Figure 1. Diagnosed flow chart for acute hematochezia in our institution; *The choice of CTA or angiography or colonoscopy depend on patien's condition and decision making of attending physican; CTA = computer tomography angiography; DRE = digital rectal examination

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The bleeding was successfully treated via transanal suture ligation in all patients, and no complications were present after the procedure. Eight patients developed recurrent bleeding following transanal suture ligation of the bleeder. The duration from initial suture ligation to recurrent bleeding ranged from three to ten days. In our study, 17 patients died due to other comorbid diseases.


  Discussion Top


Acute massive LGI hemorrhage is commonly found in ICU patients, and the disease is a common clinical problem with multiple causes, including rectal ulcer, hemorrhoids, angiodysplasia, diverticulosis, and ischemic colitis. The major causes of LGI bleeding in hospitalized patients are ischemic colitis and rectal ulcers. [1],[2],[6] It has been reported previously that AHRU is the most common cause of acute LGI bleeding in ICU patients. [3]

'Acute hemorrhagic rectal ulcer' was first described by Soeno et al.,[7] in Japan, and then Fujimaki et al. [8] reported it as a syndrome. The clinical characteristics of AHRU are that it most commonly occurs in elderly, bed-ridden patients, with severe underlying illnesses, [4],[9],[10] who present with sudden onset, painless, massive rectal bleeding. Most of our patients had these symptoms.

Rectal ulcer has the following differential diagnoses: Radiation rectal ulceration, solitary rectal ulcer syndrome, ischemic proctitis, stercoral ulcer, and rectal ulcers secondary to treatment with nonsteroidal compounds. A stercoral ulcer is an impaction of fecal material with pressure compression on the colonic wall. The lesion is usually located in the rectosigmoid area, and occurs in constipated, bedridden patients. Solitary rectal ulcer syndrome predominantly occurs in young adults with a history of constipation, self-digitation, or rectal prolapse, and presents as rectal bleeding, mucous discharge, and tenesmus. Ischemic proctitis usually presents as diarrhea, rectal bleeding, fever, abdominal pain, and leukocytosis. The clinical history and symptoms mentioned above are not similar to those of our patients. In our study, no patient had a history of pelvic radial therapy or treatment with nonsteroidal compounds.

The mechanism of AHRU is still unclear. Nakamura et al. [11] reported the effect of a change in position on blood flow in the rectal mucosa, and explained that bedridden patients had a higher risk of AHRU.

If a patient has a life-threatening lower gastrointestinal hemorrhage, early detection of the bleeding source and treatment are challenges in clinical practice. In our hospital, if the patient has a fresh bloody stool and the blood is not mixed with stool, emergency anorectal bleeder checking via an anoretractor is performed. The examination can safely, quickly, and easily diagnose anorectal bleeding. If an anorectal bleeder is found, emergency suture ligation of the bleeder is performed. Transanal suture ligation of anorectal bleeders can be performed safely at the bedside without major complications.

There are advantages and disadvantages of per anal suture at the bedside. The advantages are that only simple tools are needed, it can be quickly performed, continuous hemodynamic monitoring and resuscitation are possible, and patients do not need to be transferred. The disadvantages are that an upper rectum bleeder cannot be controlled by per anal suture, the light quality at the bedside is poor, and placement of the anoretractor over the rectum can make the patient uncomfortable.

A previous report showed that the recurrent bleeding rate following endoscopic hemostasis of AHRU was 48.3%, and the study showed that patients who suffered hypovolemic shock and received anticoagulants were more likely to develop re-bleeding after endoscopic treatment (P = 0.005). [3] In our study, the recurrent bleeding rate of transanal suture ligation of AHRU was 25%, and the duration from the first hematochezia attack to surgery (P = 0.04), liver cirrhosis (P = 0.002), and coagulopathy (P = 0.01) were risk factors for recurrent bleeding after suture ligation of the bleeder. Liver cirrhosis (OR = 37.77, P = 0.014) was an independent risk factor.

There are limitations of our study. First, due to the retrospective design of our study, we may not be able to provide accurate data and information regarding the patient's general condition. Second, ICU patients have multiple severe diseases, and there may have been cofactors related to the recurrent bleeding that we were not able to identify. Third, there is a small sample size in the study; larger sample size studies are required to validate our results.


  Conclusion Top


Acute hemorrhagic rectal ulcer is life threatening and it is also an important cause of acute massive hematochezia in patients with severe illness. Our data showed that per anal suture could quickly and effectively control bleeding and resulted in a lower rate of recurrent bleeding than endoscopic hemostasis. However, the recurrent bleeding rate was still high after suture ligation of bleeders. We found that liver cirrhosis was an independent risk factor for recurrent bleeding, and suggest that physicians treat such patients more aggressively.


  Disclosure Top


All authors declare no competing financial interests.

 
  References Top

1.Lin CC, Lee YC, Lee H, Lin JT, Ho WC, Chen TH, et al. Bedside colonoscopy for critically ill patients with acute lower gastrointestinal bleeding. Intensive Care Med 2005;31:743-6.  Back to cited text no. 1
    
2.Kim BC, Cheon JH, Kim TI, Kim WH. Risk factors and the role of bedside colonoscopy for lower gastrointestinal hemorrhage in critically ill patients. Hepatogastroenterology 2008;55:2108-11.  Back to cited text no. 2
    
3.Lin CK, Liang CC, Chang HT, Hung FM, Lee TH. Acute hemorrhagic rectal ulcer: An important cause of lower gastrointestinal bleeding in the critically ill patients. Dig Dis Sci 2011;56:3631-7.  Back to cited text no. 3
    
4.Takeuchi K, Tsuzjki Y, Ando T, Sekihara M, Hara T, Ohno Y, et al. Clinical characteristics of acute hemorrhagic rectal ulcer. J Clin Gastroenterol 2001;33:226-8.  Back to cited text no. 4
    
5.Hung HY, Changchien CR, You JF, Chen JS, Chiang JM, Yeh CY, et al. Massive hematochezia from acute hemorrhagic rectal ulcer in patients with severe comorbid illness: Rapid control of bleeding by per anal suturing of bleeder using anoretractor. Dis Colon Rectum 2006;49:238-43.  Back to cited text no. 5
    
6.Hendrickson RJ, Diaz AA, Salloum R, Koniaris LG. Benign rectal ulcer: An underground cause of inpatient lower gastrointestinal bleeding. Surg Endosc 2003;17:1759-65.  Back to cited text no. 6
    
7.Soeno T, Shoji S, Sakuraba K. Acute hemorrhagic rectal ulcer accompanied with the brain disease (in Japanese with English abstract). Akita J Med 1981;8:207-13.  Back to cited text no. 7
    
8.Fujimaki E, Sugawara M, Inoue Y. Endoscopical findings and clinical features of acute rectal ulcers (in Japanese with English abstract). Gastroenterol Endosc 1993;35:2421-5.  Back to cited text no. 8
    
9.Tseng CA, Chen LT, Tsai KB, Su YC, Wu DC, Jan CM, et al. Acute hemorrhagic rectal ulcer syndrome: A new clinical entity? Report of 19 cases and review of the literature. Dis Colon Rectum 2004;47:895-905.  Back to cited text no. 9
    
10.Oku T, Maeda M, Ihara H, Umeda I, Kitaoka K, Waga E, et al. Clinical and endoscopic features of acute hemorrhagic rectal ulcer. J Gastroenterol 2006;41:962-70.  Back to cited text no. 10
    
11.Nakamura S, Okawa K, Hara J. Etiology of acute hemorrhagic rectal ulcer Laser-Doppler analysis of rectal mucosal blood flow in lateral and horizontal supine position at bed rest [in Japanese with English abstract]. Gastroenterol Endosc 1996;38:1481-7.  Back to cited text no. 11
    


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    Tables

  [Table 1], [Table 2]



 

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