New onset rectal bleeding

  • Brian M. Fung
    Correspondence
    Corresponding author at: Banner – University Medical Center Phoenix, 1111 E McDowell Road, Internal Medicine, LL2, Phoenix, AZ 85006, USA.
    Affiliations
    Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA

    Banner – University Medical Center Phoenix, Phoenix, AZ, USA
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  • Kelly M. Zucker
    Affiliations
    Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA

    Banner – University Medical Center Phoenix, Phoenix, AZ, USA
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  • Joseph David
    Affiliations
    Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA

    Banner – University Medical Center Phoenix, Phoenix, AZ, USA

    Arizona Digestive Health, Phoenix, AZ, USA
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Published:October 24, 2021DOI:https://doi.org/10.1016/j.ejim.2021.10.010

      Keywords

      1. Case description

      A 36-year-old male with no significant past medical history presented to the emergency department for new onset hematochezia. Prior to arrival, the patient reported having five episodes of passing bloody stool and frank blood without associated abdominal or rectal pain, nausea, vomiting, or fever. He denied rectal trauma including anal receptive intercourse. He was not on any prescription medications. On physical examination, his vital signs were normal. His abdominal examination was unremarkable, and digital rectal examination revealed an empty rectal vault. No external hemorrhoids were noted. Laboratory tests were significant for a hemoglobin of 9.0 g/dL (baseline 13.7 g/dL). The patient was admitted, consented, and prepared for colonoscopy scheduled for the next day. The following morning, the patient's hemoglobin was noted to be 6.0 g/dL. After transfusion of 2 units of packed red blood cells, colonoscopy was performed; a lesion is found in the rectum ([ ]Fig. 1A). What is the diagnosis?
      Fig. 1
      Fig. 1Endoscopic images of large rectal ulcer with (A) active bleeding from a large purpuric blood vessel, (B) continued bleeding after injection with 1:10,000 solution of epinephrine, (C) positioning of Ovesco clip pre-deployment, and (D) successful hemostasis after placement of Ovesco clip.

      2. Discussion

      Colonoscopy revealed a 1.3 cm ulcer with a large actively bleeding vessel in the distal rectum ([]Fig. 1A). The area around the ulcer was injected with epinephrine ([]Fig. 1B) and an over-the-scope clip ([]Fig. 1C) was subsequently placed to achieve hemostasis ([]Fig. 1D). On further questioning, the patient admitted to hiding methamphetamine and an insulin syringe in his rectum several hours prior in an attempt to avoid arrest. The patient was counseled on the dangers of this high-risk activity and was discharged the following day without further complications.
      “Body pushing” refers to the concealment of illegal drugs within the human body to avoid arrest.[
      • Byard R.W.
      • Kenneally M.
      Body pushing, prescription drugs and hospital admission.
      ] Unlike “body packing”, which is the internal concealment of illegal drugs for the purpose of transporting large quantities of drugs, body pushing often involves hastily hiding drugs, often loosely wrapped in thin paper or cellophane and inserted into the rectum or vagina, resulting in an increased risk of drug absorption.[
      • Havis S.
      • Best D.
      • Carter J.
      Concealment of drugs by police detainees: lessons learned from adverse incidents and from ‘routine’ clinical practice.
      ,
      • June R.
      • Aks S.E.
      • Keys N.
      • Wahl M.
      Medical outcome of cocaine bodystuffers.
      ] In this case, the patient was fortunate not to experience systemic drug absorption. However, he suffered life-threatening blood loss due to the ulceration caused by placement of a rigid object (syringe) and drugs in the rectum. Although patients will not always be forthcoming about these practices, a detailed patient history, including asking about rectal insertions in the proper clinical setting, should be taken in patients with new onset rectal bleeding.

      CRediT authorship contribution statement

      BMF drafted the manuscript and formatted figures. KMZ critically reviewed the manuscript. JD provided supervision and is the article guarantor. All authors approved the final version of this manuscript.

      Financial support

      None.

      Declaration of Competing Interest

      None.

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