S4646 Biopsy Backfire: Large Volume Rectal Bleeding Following Transrectal Prostate Biopsy

Introduction: Transrectal ultrasound (TRUS) guided prostate biopsy is the gold standard for prostate cancer diagnosis in men. Mild and self-limited rectal bleeding is a frequently cited complication, while symptomatic blood loss necessitating endoscopic intervention is rarely encountered. Endoscopic interventions include sclerotherapy, epinephrine injection, hemoclip application, band ligation, and electrocautery. We present a case of severe rectal bleeding following a transrectal prostate biopsy, successfully managed with endoscopic clipping. Case Description/Methods: An 86-year-old man with a history of abdominal aortic aneurysm repair on clopidogrel, coronary artery disease, and benign prostatic hyperplasia presented to the emergency department due to significant hematochezia that began 6 hours after undergoing TRUS prostate biopsy. His blood pressure was 60/40 and heart rate was 140 with a hemoglobin of 9.1 g/dL (12.5 g/dL at baseline). Computed tomography angiography showed contrast in the rectal vault with no active extravasation. Clopidogrel had been held 7 days prior to admission, and no anticoagulation or venous thrombosis prophylaxis was given. He was given 1 unit of blood. However, he continued to have hematochezia, with further hemoglobin decrease to 7.0 g/dL. Flexible sigmoidoscopy was urgently performed, which demonstrated localized erythematous mucosa with a visible vessel in the rectum. A hemostatic clip was deployed, achieving hemostasis. Clopidogrel was resumed without further bleeding or other complications. He was discharged home with urology follow-up. Discussion: Severe rectal bleeding requiring intervention occurs in fewer than 1% of prostate biopsies. Both immediate and delayed hematochezia have been reported. Reporting such cases is essential for identifying effective interventions and relevant risk factors such as anticoagulant/antiplatelet use and the number/location of core biopsies taken. Fortunately, multiple endoscopic techniques are available to achieve hemostasis; in this case, hemostatic clip deployment proved effective. Radiological embolization and surgical approaches are alternative options for management. The low reported incidence may reflect under-recognition or underreporting, as most data is derived from isolated case reports. By documenting this case, we aim to contribute to the existing literature, enhance clinical understanding, and support interventionalists in managing this uncommon but potentially serious complication.