Rectal Tear: A Rare Cause of Gastrointestinal Bleeding

Abstract

We present the case of a 52-year-old male with a past medical history of double-lung transplantation in the context of alpha-1 antitrypsin deficiency, complicated by chronic lung allograft dysfunction (bronchiolitis obliterans syndrome), and two perianal interventions (fistulotomy and hemorrhoidectomy) 5 years before. The patient was admitted to our hospital due to acute-on-chronic respiratory failure as a result of respiratory infection. In the intermediate care unit, he started noninvasive ventilation, broad-spectrum antibiotherapy, and thromboprophylactic enoxaparin 40 mg daily. Due to constipation, even taking osmotic laxatives, daily docusate sodium and sorbitol enemas were initiated as well. Five days later, the patient had new-onset rectal bleeding, without abdominal or anal pain. Laboratory data showed a hemoglobin level of 6.4 g/dL. He required intravenous fluids and blood transfusions for resuscitation. Due to persistent rectal bleeding with associated hemodynamic instability, a flexible sigmoidoscopy was performed after cleansing enema administration. An extensive tear of the distal rectum with exposure of the muscular layer was evident (Fig. 1a), as well as two fistula openings with many clots and associated spurting bleeding (Fig. 1b). Hemostasis was achieved after the injection of 9 mL of diluted adrenaline (1: 10,000) and placement of 6 hemoclips (Fig. 2). Computed tomography angiography was performed immediately after the procedure, which showed parietal thickening of the terminal portion of the rectum, with associated fistulous tracts containing gas (Fig. 3). There was no evidence of active bleeding, perforation, or intra-abdominal collections. No further episodes of bleeding occurred after endoscopic therapy. However, the respiratory failure gradually worsened and the patient was refused for retransplantation. He died a week later. Besides the previous perianal interventions, there was no history of recent trauma, anal intercourse, or endoscopic or surgical procedures. Therefore, the rectal tear was probably caused by the administration of a cleansing enema to a debilitated patient with reduced complaints of