Luminis Health/ Anne Arundel Medical Center Pasadena, MD
Nirav Agrawal, MD, MPH1, Scarlet Louis-Jean, MD, MBA, MSAN2, Steven Fleisher, MD3 1Luminis Health/ Anne Arundel Medical Center, Pasadena, MD; 2Luminis Health/ Anne Arundel Medical Center, Annapolis, MD; 3Luminis Health Anne Arundel Medical Center, Annapolis, MD
Introduction: Acute hemorrhagic rectal ulcer (AHRU) is an increasingly recognized cause of lower gastrointestinal bleeding characterized by sudden onset painless, profuse rectal bleeding from solitary or multiple ulcers. The pathogenesis likely involves mucosal prolapse and shearing forces from paradoxical puborectalis contractions during defecation. While endoscopic therapies are first-line, some cases are refractory due to ulcer location or diffuse disease. Vaseline gauze packing has rarely been described to promote hemostasis and ulcer healing in AHRU. We present a refractory case successfully treated with this adjunct.
Case Description/Methods: A 78-year-old man with end-stage renal disease, prostate cancer after radiation, and recent hip fracture presented with acute painless hematochezia, and hypotension requiring transfusion. Imaging showed active rectosigmoid bleeding. Emergent sigmoidoscopy revealed two 1cm actively bleeding rectal ulcers proximal to the dentate line treated with cautery and clipping. Despite this, massive hematochezia continued requiring multiple transfusions over 2 days. Repeat sigmoidoscopy on hospital day 3 showed persistent oozing from ulcers at the distal posterior rectum near the dentate line. As further banding or thermal therapy was unfeasible, epinephrine injection provided only temporary hemostasis. The anal canal was packed with Vaseline gauze as tamponade given the difficult location. No re-bleeding occurred, and the gauze was removed after 24 hours. The patient left against advice on day 5 but returned in 2 weeks with no recurrence.
Discussion: AHRU is an increasing concern for lower gastrointestinal bleeding. Endoscopic treatment can be challenging when ulcers are near the dentate line due to limited space. Only two prior cases describe using Vaseline gauze for refractory AHRU in this location, with successful hemostasis and healed ulcers on follow-up endoscopy. Vaseline packing provided hemostasis for posterior rectal ulcers abutting the dentate line refractory to standard endoscopic methods. The lack of re-bleeding over 2 weeks suggests the ulcers healed, though direct endoscopic re-evaluation was not performed. While more study is needed, this simple, low-cost adjunct may reduce the need for invasive surgery in refractory AHRU. In conclusion, Vaseline gauze rectal packing provided safe, effective hemostasis in this refractory case and may promote ulcer healing, warranting further study of this therapeutic option for managing severe AHRU.
Figure: The sigmoidoscopic imaging of the rectum demonstrating diffuse superficial ulceration of up to 2-3 cm in a serpiginous fashion likely consistent with ischemic/stercoral ulcer noted (A, B). Visualization proved difficult secondary to the degree of blood and clot in the lumen. This was suctioned and washed (C), ultimately exposing fresh oozing at an area abutting the dentate line in the distal posterior rectum around the site where prior clips were placed (D). This area is in the vicinity of the hemorrhoid complex, and may represent a complicated hemorrhoid as a source of bleed (E, F). Nevertheless, ulceration extended to this region, with much tissue maceration, the bleeding was treated with injection with a total of 4 cc of 1:10000 epinephrine, which successfully caused the bleeding to stop (G). In an effort to prevent rebleed once the effect of epinephrine wears off, the anal canal was packed with gauze infused with vaseline (not shown).
Disclosures:
Nirav Agrawal indicated no relevant financial relationships.
Scarlet Louis-Jean indicated no relevant financial relationships.
Steven Fleisher indicated no relevant financial relationships.
Nirav Agrawal, MD, MPH1, Scarlet Louis-Jean, MD, MBA, MSAN2, Steven Fleisher, MD3. P0820 - Acute Hemorrhagic Rectal Ulcer Managed With Vaseline Gauze: A Case Report of an Effective Adjunctive Modality, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
