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).