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Anorectal Outlet Sources. Giuseppe Gagliardi, MD Mario Pescatori, MD, FRCS Coloproctology Unit, Rome Villa Flaminia. Acute bleeding:anorectal causes. More common Less common Hemorrhoids Rectal varices Post-surgical Angiodysplasya Post-polypectomy* SRU

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anorectal outlet sources

Anorectal Outlet Sources

Giuseppe Gagliardi, MD

Mario Pescatori, MD, FRCS

Coloproctology Unit, Rome Villa Flaminia

acute bleeding anorectal causes
Acute bleeding:anorectal causes

More commonLess common

Hemorrhoids Rectal varices

Post-surgical Angiodysplasya

Post-polypectomy* SRU

Radiation proctitis* Stercoral ulcer

Neoplasms Dieulafoy

IBD Aneurysms


treatment of hemorrhoidal bleeding
Treatment of hemorrhoidal bleeding

Rubber band ligation vs excisional hemorrhoidectomy: no difference for bleeding symptoms

Cochrane 2005

Bleeding after RBL 25% patients taking warfarin


2.9% patients taking neither

Iyier DCR 2004

Hemorrhoidectomy with Ligasure in anticoagulated patients

Lawes Colorectal Dis 2004

treatment of hemorrhoidal bleeding1
Treatment of hemorrhoidal bleeding

Morar Cardiovasc Intervent Radiol 2006

bleeding after hemorrhoid treatment
Bleeding after hemorrhoid treatment

Reactionary: technical errors incidence 1%

PPH vs excisional hemorrhoidectomy (for PPH 1.8-44% reoperation 25-90%)

Secondary: after 6-11 days incidence 2.4-6%.

Treatment: Anal packing 15% rebleed

Hemostatic sponge

Rectal Foley

Adrenaline injections

Rectal irrigation 12% don’t stop Chen DCR 2002

Suturing required in 7%-40%

followed by late complications in 15%

Mazier Semin Colon Rectal Surg 1990

? role of micronized flavonoids

rectal varices
Rectal Varices

Incidence in portal hypertension 44-90% > in viral cirrhosis Chawla Gut 1991

Bleed in 10%-37%, independent from Child’s classification





TIPPS vs TIPPS + embolization 42 vs 28% rebleed

Vangeli J Hepatology 2004

Venus shunts

Resective surgery contraindicated

anorectal tumors
Anorectal tumors

Is resection necessary for palliation?

Local recurrence

After surgery clinical improvement in 78%(curative) 40%(palliative), in the long term 63% and 88%% and develop symptoms Miner Ann Surg Oncol 2003

EXTR and re-XRTshort term palliation for non-metastatic, bleeding palliated

Mohiuddin Cancer 2002

EXRT+hyperthermia 72% immediate palliation Juffermans Cancer 2003

Brachytheraphy 60-90% response for bleeding Hoskins Radiother Oncol 2004

Metastatic disease

EXRT 90% of patients with metastastic disease palliated until death

Crane Int J Radiat Oncol Biol Phys. 2001

Long term palliation in 75% with (repeated) APC

Gevers Gastrointest Endosc 2000

anorectal tumors1
Anorectal Tumors

Surgery indicated for palliation in patients with > 6 months life expectancy

Fazio J Gastrointest Surg 2004

Resection and anastomosis in patients with metastatic disease

Moran Arch Surg 1987

Hartmann vs Abdominoperineal to avoid perineal wound sepsis and pain

Heah DCR 1997

Local excision equivalent palliation

Chen J Gastrointest Surg 2001

Anorectal melanoma

Presents with bleeding, beware of amelanotic lesions

Treatment is surgical

Survival and recurrence not dependent on surgical strategy (LE=APR)

Yeh ASCRS 1995

anorectal bleeding ibd
Anorectal bleeding:IBD

Acute Fulminant Colitis

In pre-pouch era 20% of acute bleedings underwent proctectomy

In emergency IRA for bleeding 18% rebleed from rectum but massive bleeding rare

Robert Am J Surg 1990

Emergency IPAA with low morbidity Ziv DCR 1994; Ham DCR 1994

Emergency IPAA higher septic and obstructive complications Penna DCR 1993

Medical theraphy, rectal foley, adrenaline, endoscopic, embolization* *Mallant-Hent Eur J Gastroenterol Hepatol 2003


Bleeding from left colon ulcer

Medical 60% endoscopic 20% surgery 20% Balaiche AJG 1999

rectal ulcer
Rectal Ulcer

Dieulafoy, Acute hemorrhagic rectal ulcer, aspecific ulcer


Stercoral ulcer

Frequency underestimated (1.7-5% in autopsy)

Elderly, bedridden, constipated

Pressure ulcer of necrosis, fecaloma

Sigmoid=perforation Rectum=bleeding

Aspecific chronic and acute inflammation

Solitary rectal ulcer


Sclerotheraphy1, clipping, cauterization, APC, suturing, embolization2, surgery

1Matsushita Gastrointestinal Endoscopy 1998

2Dobson Cardiovascular and Interventional Radiology 1999



Rubber Bleb Nevus Syndrome

Hemangioma capillary




Sclerotherphy, APC, endoscopic banding, EXRT

Surgery: LAR, mucosectomy and coloanal sleeve anastomosis

Londono-Schimmer BJS 1994


Rigid sigmoidoscopy and rectal washout should be part of the work-up of patients presenting with bright red blood per rectum

Some of the causes are rare and require specialist input in tertiary care centers

Most of anorectal acute bleedings can be controlled without laparotomy

Embolization of rectal arteries carries low morbidity