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Massive rectal bleeding
Massive J. C. QUATKANO,
M.D. AND
Rectal P. D. HENRY,
f>feeding is a common complaint in proctologic practice. The causes are numerous and varied, and the proctofogist must be on the alert for disease anywhere in the gastrointestinaf tract intruding upon the rectum. The foffowing case is presented to iflustrate one of the rarer causes of rectal bleeding, Ijut one which may be diagnosed in the ofice.
R
ECTAL
CASE
REPORT
The patient, a fifteen year ofd boy presentecI himself to the proctofoglst’s of&e on October I, 1954, with the compfaint of rectal bfeeding of four days’ duration. One \veek previousfv he had noted sharp periumbificaf pain which lasted twenty-four hours. No anorexia, vomiting or abnormal stoofs were noted. Two days fater the pain recurrecf and the patient passed a black stoof. Another f,owef movement fater in the day was stainecI with bright red blood, and a recurrence of crampy abdominal pain was noted in the left lower quadrant of the abdomen. The patient had two bowel movements a day during the next three days, each stained with bright red bfood, and therefore sought medicaf advice. Sigmoidoscopy performed in the offIce was unsatisfactory due to bfeeding which obscured the bowef; however, no abnormalities were noted in the anus or lower rectum. The boy was admitted to St. Vincent’s Hospitaf with a diagnosis of bleeding from a Meckef’s diverticufum. Past history reveaIed that he had aIways been anemic and sickIy and that he had had an episode of bright red recta1 bIeeding at the age of twenty months. At that time he was hospitaIized for two weeks, requiring several transfusions. However, repeated x-rays reveaIed no ahnormaIities of the bowef. He was
Bleeding M.D., Bridgeport,
Connecticut
also saicl to have had pinworms which \rere blamed for intermittent crampy pain in the left lower quadrant of the abcfomen cluring the preceding year. There were no tarry stools or rectal bleeding since infancv, but occult bIood was detected on one occasftin during the episodes of pain in the left lower quadrant of the abdomen. There were no known congenital anomalies in the patient’s famify. Physical examination revealed a thin, very paIe, apprehensive boy who seemed somewhat retarded for fifteen years but in no acute distress. Blood pressure was I 16/68, pulse I 12, and temperature 98.6%. The physica findings were confined chiefly to the abdomen which showed miId spasm of the rectus muscIes with tenderness elicited in the left lower quadrant on deep paIpation. There was no rebound tenderness or paIpabIe masses. Rectal examination revealed no masses or hemorrhoids and no tenderness, but dark stoo1 and bright red blood were noted on the examining finger. Laboratory findings were as follows: red bfood cell count, 2.8 million per cu. mm.; hemoglobin, 7.5 gm. per cent; white bIood cell count, 22,000 per cu. mm. UrinaIysis was essentiaIIy negative. The patient’s bIood was typed and cross matched; 500 cc. of blood were given ant1 a gastrointestina1 series and barium enema were scheduled. The bIood pressure, which had dropped to go/8a, was stabiIized at I 12/70 that night after administration of $00 cc. of bIood. The next morning the patient vomited his breakfast and passed a Iarge, dark red stool. A repeat complete bIood count reveaIed a ret1 bIood ceI1 count of 2.2 miIIion per cu. mm. and a hemogIobin of 6.5 gm. per cent. Despite the administration of 1,000 cc. of whole bIooc1, blood pressure remained around g6/so. There.fore, the patient was prepared for surgery.
Massive
Recta1
BIeeding colonic, biliary and jejunal eIements are occnsionally seen. The diverticulum is subject to important pathologic changes such as inflammation, peptic ulcer, intussusception, perforation, volvulus, Littre’s hernia and hstula formation. Although it may manifest itself at any age, almost half of the patients in Gross’ series were under the age of two when admitted to the hospital. The anomaIy has rareIy been demonstrated roentgenoIogicaIly despite its occurrence in 2 per cent of the population [4]. Hemorrhage is the chief compIication of RiIeckeI’s diverticulum and may f>e due to peptic ukeration, inflammation, erosion and, rarely, neoplasm [6,7]. It is most frequentI> clue to peptic uIcer, presumably from digestion of the neighboring mucosa by the pepsin and hydrochloride secreted by the aberrant gastric tissue. This complication is two to live times as common in boys as it is in girls; 74 per cent of hemorrhages occur in children under the age of fifteen, but they have been encountered at operation in persons ranging in age from two Reeks to seventy-seven years [2]. In Gross’ series, 80 per cent of all instances of hemorrhage occurred in children under the age of two [I]. In chiIdren this condition is manifested by the sudden passage of a copious black stool, without previous symptoms, and a subsequent bright red or brick-colored stoo1. BIeeding is massive and the red blood celI count may drop to 1.5 or 2 million per cu. mm. There may be no pain or only- mild discomfort, generally in the periumbilical region. Bockus [4] remarks on the periodicity of severe internal bleeding associated with this anomaly and believes the diagnosis is strengthened by a family history of other congenital anomalies. The differential diagnosis includes intussusception, rectal and colonic polyps, hemorrhoids, hssures, peptic ulcer and hemorrhagic diathesis. In intussusception there is a more agonizing crampy abdominal pain and other signs of obstruction such as vomiting, plus the currant jeIly stool. However, Meckel’s diverticulum may imitate intussusception. Rectal and colonic polyps are Iess IikeIy to cause severe bleeding. Most frequently the blood occurs in streaks in mucus, especialIy after bowel movements. The diagnosis may be confirmed by sigmoidoscopy and barium enema. Hemorrhoids and Iissures may be detected proctoscopically.
At operation, performed that evening, a right paramedian incision was made 2 inches abo\-e and beIow the umbilicus. A Meckel’s diverticulum was present about 2 feet above the ileocecal vaIve. It was adherent to the mesentery of the ileum and measured 2 cm. in length. Because of the difficulty in freeing the diverticulum, local resection of the ileum and ileoileostomy were performed. On opening the ileum, a bleeding point was noted in an uIcer located just at the neck of the diverticulum. The pathologic report showed the diverticuIum to be Iined partIy by intestimd mucosn and partly fly gastric mucosa. At the junction of the two was a peptic uIcer, 8 mm. in diameter, which invaded the submucosa and partly the muscuIaris and was bordered by a wide zone of inflammatory tissue. The patient had an uneventfu1 postoperative course with stabilization of bIood pressure at 132/10o, and was discharged six days after admission. COMMENTS
MeckeI’s diverticulum is not commonly encountered by the proctologist. However, when one considers that it occurs in 2 per cent of the population [I] and gives symptoms in from 13 to 20 per cent of those possessing it [2,7,8], it shouId be considered in the differential diagnosis of unexpIained rectal bleeding, especialI? in a child. It is the most frequently occurring developmental anomaly of the gastrointestina1 tract and results from the failure of the intestine to lose its connection with the yoIk sac, normally occurring in the sixth to seventh embryonic week [?I. DeveIopmentaIIy, failure to lose this connection may Iead to the diverticulum or a persistent omphalomesenteric duct or any combination of conditions between the two. It occurs on the antimesenteric border of the ileum, generaIly from 18 to 30 inches above the iIeoceca1 valve, but has been found, according to Moses, in all parts of the gastrointestinal tract from the stomach to the rectum [2]. It has a diameter generaIIy Iess than the iIeum, although giant forms may exist, and may vary in Iength from 44 to 3 inches [I]. One of the most interesting features of MeckeI’s diverticuIum is the presence of heterotopic tissue in approximately 35 per cent of the cases [2,4]. Gastric mucosa is most commonly encountered, aIthough pancreatic, duodenal, 87
Quatrano
and Henry
Peptic ulcer may be suggested bv the histoq, the patient’s age, epigastric pain, response to alkalis and barium studies. The hemorrhagic diathesis may be suggested hq’ the history, and blood stucfies should confirm the diagnosis. The patient reportecf fzerein had an almost typical history of hemorrhage from a Meckef’s diverticufum, especially so with the episode of undiagnosed rectal bfeeding occurring at the age of twenty months. It is a matter of conjecture as to whether or not intermittent occult bIeeding caused the anemia and contributed toward the apparent mental retardation. The treatment is transfusion and early surgery in the manner advocated hy Ladd and Gross.
Some salient facts relative to Meckef’s cfiverticulum are reviewecf to assist tfie proctologist in estaflfishing an early diagnosis. REFERENCES
I. GROSS, R. E. The Surgery of Infancy and Childhood, pp. 21 I-220. Philadelphia, 1953. W. B. Saunders
CO. W. R. hlcckcl’s diverticulum; report of two unusual crises.. New Englund J. Med., 237: I 18, 1947. 3, PER.BERTHY,G. C. and BENSON, C. D. Complications of hleckel’s divertictdum in infants and children. S. Clin. North America, 28: 1221-1231, 1948. vol. II, p. 54. 4. BOCKUS, II. D. Gastroenterology, Philadelphia, 1949. W. B. Saunders Co. i;. HARRIS. J. W. POIVDS of rectum and colon in chil> dren. Am. J. Surg., 86: 577-582, 1953. 6. FKEEDX\IAX,hl. A.,’ CHAIV&, 0. P., -HARRIS, L. E. nnd KIRKLIN. J. W. hleckef’s diverticulum in infsnts and children. Am. J. Surg., 87: 160, 1954. 7. HILL, F. A. and JAKELLI, D. E. Malignant tumors originating in Meckel’s divcrticulum. Am. J. Surg., 85: 525-528, 1953. 8. COKNELL, G. N. >rnd BARNES, W. A. hleckel’s diverticulum; report of roe CBSCS. New York StateJ. Med., 54: 529--$33. 1954. 2. hlos~s,
rl
SUMMARY
A case of massive rectal bfeeding in a fifteen year ofd boy is presented. The history, physical findings and course of the iffness were typical of hemorrhage from a Meckef’s diverticufum and the diagnosis was confirmed at surgery.
88
M.D. AND
Rectal P. D. HENRY,
f>feeding is a common complaint in proctologic practice. The causes are numerous and varied, and the proctofogist must be on the alert for disease anywhere in the gastrointestinaf tract intruding upon the rectum. The foffowing case is presented to iflustrate one of the rarer causes of rectal bleeding, Ijut one which may be diagnosed in the ofice.
R
ECTAL
CASE
REPORT
The patient, a fifteen year ofd boy presentecI himself to the proctofoglst’s of&e on October I, 1954, with the compfaint of rectal bfeeding of four days’ duration. One \veek previousfv he had noted sharp periumbificaf pain which lasted twenty-four hours. No anorexia, vomiting or abnormal stoofs were noted. Two days fater the pain recurrecf and the patient passed a black stoof. Another f,owef movement fater in the day was stainecI with bright red blood, and a recurrence of crampy abdominal pain was noted in the left lower quadrant of the abdomen. The patient had two bowel movements a day during the next three days, each stained with bright red bfood, and therefore sought medicaf advice. Sigmoidoscopy performed in the offIce was unsatisfactory due to bfeeding which obscured the bowef; however, no abnormalities were noted in the anus or lower rectum. The boy was admitted to St. Vincent’s Hospitaf with a diagnosis of bleeding from a Meckef’s diverticufum. Past history reveaIed that he had aIways been anemic and sickIy and that he had had an episode of bright red recta1 bIeeding at the age of twenty months. At that time he was hospitaIized for two weeks, requiring several transfusions. However, repeated x-rays reveaIed no ahnormaIities of the bowef. He was
Bleeding M.D., Bridgeport,
Connecticut
also saicl to have had pinworms which \rere blamed for intermittent crampy pain in the left lower quadrant of the abcfomen cluring the preceding year. There were no tarry stools or rectal bleeding since infancv, but occult bIood was detected on one occasftin during the episodes of pain in the left lower quadrant of the abdomen. There were no known congenital anomalies in the patient’s famify. Physical examination revealed a thin, very paIe, apprehensive boy who seemed somewhat retarded for fifteen years but in no acute distress. Blood pressure was I 16/68, pulse I 12, and temperature 98.6%. The physica findings were confined chiefly to the abdomen which showed miId spasm of the rectus muscIes with tenderness elicited in the left lower quadrant on deep paIpation. There was no rebound tenderness or paIpabIe masses. Rectal examination revealed no masses or hemorrhoids and no tenderness, but dark stoo1 and bright red blood were noted on the examining finger. Laboratory findings were as follows: red bfood cell count, 2.8 million per cu. mm.; hemoglobin, 7.5 gm. per cent; white bIood cell count, 22,000 per cu. mm. UrinaIysis was essentiaIIy negative. The patient’s bIood was typed and cross matched; 500 cc. of blood were given ant1 a gastrointestina1 series and barium enema were scheduled. The bIood pressure, which had dropped to go/8a, was stabiIized at I 12/70 that night after administration of $00 cc. of bIood. The next morning the patient vomited his breakfast and passed a Iarge, dark red stool. A repeat complete bIood count reveaIed a ret1 bIood ceI1 count of 2.2 miIIion per cu. mm. and a hemogIobin of 6.5 gm. per cent. Despite the administration of 1,000 cc. of whole bIooc1, blood pressure remained around g6/so. There.fore, the patient was prepared for surgery.
Massive
Recta1
BIeeding colonic, biliary and jejunal eIements are occnsionally seen. The diverticulum is subject to important pathologic changes such as inflammation, peptic ulcer, intussusception, perforation, volvulus, Littre’s hernia and hstula formation. Although it may manifest itself at any age, almost half of the patients in Gross’ series were under the age of two when admitted to the hospital. The anomaIy has rareIy been demonstrated roentgenoIogicaIly despite its occurrence in 2 per cent of the population [4]. Hemorrhage is the chief compIication of RiIeckeI’s diverticulum and may f>e due to peptic ukeration, inflammation, erosion and, rarely, neoplasm [6,7]. It is most frequentI> clue to peptic uIcer, presumably from digestion of the neighboring mucosa by the pepsin and hydrochloride secreted by the aberrant gastric tissue. This complication is two to live times as common in boys as it is in girls; 74 per cent of hemorrhages occur in children under the age of fifteen, but they have been encountered at operation in persons ranging in age from two Reeks to seventy-seven years [2]. In Gross’ series, 80 per cent of all instances of hemorrhage occurred in children under the age of two [I]. In chiIdren this condition is manifested by the sudden passage of a copious black stool, without previous symptoms, and a subsequent bright red or brick-colored stoo1. BIeeding is massive and the red blood celI count may drop to 1.5 or 2 million per cu. mm. There may be no pain or only- mild discomfort, generally in the periumbilical region. Bockus [4] remarks on the periodicity of severe internal bleeding associated with this anomaly and believes the diagnosis is strengthened by a family history of other congenital anomalies. The differential diagnosis includes intussusception, rectal and colonic polyps, hemorrhoids, hssures, peptic ulcer and hemorrhagic diathesis. In intussusception there is a more agonizing crampy abdominal pain and other signs of obstruction such as vomiting, plus the currant jeIly stool. However, Meckel’s diverticulum may imitate intussusception. Rectal and colonic polyps are Iess IikeIy to cause severe bleeding. Most frequently the blood occurs in streaks in mucus, especialIy after bowel movements. The diagnosis may be confirmed by sigmoidoscopy and barium enema. Hemorrhoids and Iissures may be detected proctoscopically.
At operation, performed that evening, a right paramedian incision was made 2 inches abo\-e and beIow the umbilicus. A Meckel’s diverticulum was present about 2 feet above the ileocecal vaIve. It was adherent to the mesentery of the ileum and measured 2 cm. in length. Because of the difficulty in freeing the diverticulum, local resection of the ileum and ileoileostomy were performed. On opening the ileum, a bleeding point was noted in an uIcer located just at the neck of the diverticulum. The pathologic report showed the diverticuIum to be Iined partIy by intestimd mucosn and partly fly gastric mucosa. At the junction of the two was a peptic uIcer, 8 mm. in diameter, which invaded the submucosa and partly the muscuIaris and was bordered by a wide zone of inflammatory tissue. The patient had an uneventfu1 postoperative course with stabilization of bIood pressure at 132/10o, and was discharged six days after admission. COMMENTS
MeckeI’s diverticulum is not commonly encountered by the proctologist. However, when one considers that it occurs in 2 per cent of the population [I] and gives symptoms in from 13 to 20 per cent of those possessing it [2,7,8], it shouId be considered in the differential diagnosis of unexpIained rectal bleeding, especialI? in a child. It is the most frequently occurring developmental anomaly of the gastrointestina1 tract and results from the failure of the intestine to lose its connection with the yoIk sac, normally occurring in the sixth to seventh embryonic week [?I. DeveIopmentaIIy, failure to lose this connection may Iead to the diverticulum or a persistent omphalomesenteric duct or any combination of conditions between the two. It occurs on the antimesenteric border of the ileum, generaIly from 18 to 30 inches above the iIeoceca1 valve, but has been found, according to Moses, in all parts of the gastrointestinal tract from the stomach to the rectum [2]. It has a diameter generaIIy Iess than the iIeum, although giant forms may exist, and may vary in Iength from 44 to 3 inches [I]. One of the most interesting features of MeckeI’s diverticuIum is the presence of heterotopic tissue in approximately 35 per cent of the cases [2,4]. Gastric mucosa is most commonly encountered, aIthough pancreatic, duodenal, 87
Quatrano
and Henry
Peptic ulcer may be suggested bv the histoq, the patient’s age, epigastric pain, response to alkalis and barium studies. The hemorrhagic diathesis may be suggested hq’ the history, and blood stucfies should confirm the diagnosis. The patient reportecf fzerein had an almost typical history of hemorrhage from a Meckef’s diverticufum, especially so with the episode of undiagnosed rectal bfeeding occurring at the age of twenty months. It is a matter of conjecture as to whether or not intermittent occult bIeeding caused the anemia and contributed toward the apparent mental retardation. The treatment is transfusion and early surgery in the manner advocated hy Ladd and Gross.
Some salient facts relative to Meckef’s cfiverticulum are reviewecf to assist tfie proctologist in estaflfishing an early diagnosis. REFERENCES
I. GROSS, R. E. The Surgery of Infancy and Childhood, pp. 21 I-220. Philadelphia, 1953. W. B. Saunders
CO. W. R. hlcckcl’s diverticulum; report of two unusual crises.. New Englund J. Med., 237: I 18, 1947. 3, PER.BERTHY,G. C. and BENSON, C. D. Complications of hleckel’s divertictdum in infants and children. S. Clin. North America, 28: 1221-1231, 1948. vol. II, p. 54. 4. BOCKUS, II. D. Gastroenterology, Philadelphia, 1949. W. B. Saunders Co. i;. HARRIS. J. W. POIVDS of rectum and colon in chil> dren. Am. J. Surg., 86: 577-582, 1953. 6. FKEEDX\IAX,hl. A.,’ CHAIV&, 0. P., -HARRIS, L. E. nnd KIRKLIN. J. W. hleckef’s diverticulum in infsnts and children. Am. J. Surg., 87: 160, 1954. 7. HILL, F. A. and JAKELLI, D. E. Malignant tumors originating in Meckel’s divcrticulum. Am. J. Surg., 85: 525-528, 1953. 8. COKNELL, G. N. >rnd BARNES, W. A. hleckel’s diverticulum; report of roe CBSCS. New York StateJ. Med., 54: 529--$33. 1954. 2. hlos~s,
rl
SUMMARY
A case of massive rectal bfeeding in a fifteen year ofd boy is presented. The history, physical findings and course of the iffness were typical of hemorrhage from a Meckef’s diverticufum and the diagnosis was confirmed at surgery.
88