Differential diagnosis, investigations and treatment:
Colonoscopy revealed nonbleeding internal hemorrhoids, grade 3. Hematin
was noted in the ascending colon. This distal ileum contained a single
localized nonbleeding aphtha however, no stigmata of recent bleeding was
seen. For further evaluation of bleeding, esophagogastroduodenoscopy was
performed, only notable for acute gastritis. The patient continued to
have bright red blood per rectum even after endoscopic intervention,
with an associated decrease in hemoglobin, on day 4 of his admission,
his hemoglobin was noted to be 8.5 g/dL. Due to the patient’s drop in
hemoglobin and persistent rectal bleeding, a capsule endoscopy is
planned to rule out small bowel lesions. Colorectal surgery was also
consulted for internal hemorrhoid management however, no surgical
intervention at that time.
The patient’s hemoglobin continued to drop, requiring a blood
transfusion. A repeat CT angiography of the abdomen and pelvis was
performed, which showed a small focus of active contrast extravasation
in the rectum with intraluminal blood in the left colon and rectum,
which was not seen on the prior imaging (Figure 1).