Acute Hemorrhagic Rectal Ulcer Presenting With Severe Lower Gastrointestinal Bleeding: A Case Report of an Emerging Entity

Acute hemorrhagic rectal ulcer (AHRU) is a rare but potentially life-threatening condition. We present the case of a 74-year-old man who developed sudden massive hematochezia and hypotension during hospitalization for fever of unknown origin. He was known to have alcohol-related liver cirrhosis, hypoalbuminemia and coronary artery disease (CAD) and was on daily aspirin. He was transfused and transferred to intensive care. Esophagogastroduodenoscopy (EGD) revealed no abnormalities, while colonoscopy showed two deep round ulcers in the distal rectum, one of which was spurting blood, promptly and successfully managed with hemoclip placement. There was no recent history of shock, constipation, or nonsteroidal anti-inflammatory drug (NSAID) use. A diagnosis of AHRU was made. The patient had no rebleeding but died two weeks later of septic shock. Gastroenterologists should consider AHRU in elderly patients with risk factors for AHRU such as prolonged bed rest, CAD, hypoalbuminemia, renal failure and anti-thrombotic drug use, who develop in-hospital lower gastrointestinal bleeding. Suggestive endoscopic findings are solitary or multiple rectal ulcer(s), with circumferential, round, Dieulafoy-like or geographical appearance and normal surrounding mucosa and location within 10 cm from the dentate line. Other etiologies should be excluded, and endoscopic hemostasis is often successful. It is important to recognize this entity and diagnose it early to decrease its associated morbidity and mortality.