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The management of fecal incontinence is a struggle to maintain patient hygiene and limit the transmission of nosocomial infections. Intrarectal devices that cause diversion and collection of the fecal stream have been used with increasing frequency. This method can effectively control patient waste if used in an appropriate setting. We examine a series of 3 patients in whom rectal trauma resulting in life-threatening hemorrhage was associated with use of the ConvaTec Flexi-Seal fecal management system. In 2 patients there was a history of traumatic removal, and the third developed a rectal pressure ulcer associated with use of this device. All 3 patients required surgical or endoscopic intervention to achieve hemostasis. Although effective, the Flexi-Seal fecal management system should be used with caution to avoid rectal trauma. Injury is most likely to occur because of traumatic removal or rectal ulceration secondary to pressure necrosis.

PURPOSE: Chronic radiation proctopathy occurs in 5 to 20% of patients receiving radiation therapy, with rectal bleeding as its most common presentation. Although formalin treatment for rectal bleeding is promising, improvement is possible. Given the success of vitamin A in other radiation-induced treatments, we studied the efficacy of combining formalin with vitamin A in controlling bleeding symptoms of chronic radiation proctopathy. METHODS: A retrospective review ( 1993-2007) was performed of patients presenting with features of chronic radiation proctopathy. Formalin 8% in a buffered solution was applied to the affected mucosa with use a tip applicator, and 10,000 units of vitamin A were given orally on a daily basis. Formalin treatments were repeated at three-week to four-week intervals until symptoms resolved. RESULTS: A comparison was made between patients who received formalin alone (n = 30) and those who received formalin in combination with vitamin A (n = 34). The 64 patients had a mean age of 79 years (range, 54-90 years). The combination group required fewer treatments (mean, 1.9) and a shorter time (11 weeks) for resolution of symptoms compared with the formalin-alone group (mean, 5.2 and 31 weeks, respectively) (P < 0.001). The overall success rate in controlling bleeding was only 64% in the formalin-alone group when compared with 94% in the combination group. CONCLUSIONS: When vitamin A was added to the regimen, a significant reduction was observed in the number of treatments and the time needed for resolution of symptoms, and there was an increased overall success rate. This combination represents a simple, effective, and well tolerated method of controlling hemorrhagic chronic radiation proctopathy.

Doppler-guided ligation of the hemorrhoidal arteries was described as an alternative to hemorrhoidectomy. The authors report their experience with this procedure.From 2002 to 2004, 100 consecutive patients underwent hemorrhoidal artery ligation procedure for symptomatic hemorrhoids and were reviewed at one month and at three years.There were 54 females. Seventy-eight patients had Grade III hemorrhoids. Eighteen patients had previously been treated for the disease. The mean operative time was 28 minutes. On average, 8.4 ligatures were placed. Seventy-nine patients were discharged the same day. Six patients presented with early complication: isolated pain in one, pain and bleeding in three, isolated bleeding in one, and obstructed defecation in one. Late complications occurred in six patients: anal pain in one, fissure in two, and thrombosis of residual hemorrhoids in three. Twelve patients presented with a recurrence at a mean delay of 12.6 months, which was treated by repeat hemorrhoidal artery ligation (n = 1), hemorrhoidopexy (n = 7), and hemorrhoidectomy (n = 4).Hemorrhoidal artery ligation procedure is safe, easy to perform, and should be considered as an alternative for the treatment of symptomatic hemorrhoids, even with a recurrence rate of 12 percent, which can be treated by the same technique or another.

Full diagnostic colonoscopy often is performed to exclude significant pathology in patients presenting with rectal bleeding. In patients with classic "outlet" bleeding, defined as bright red blood after or during defecation, with no family history of colorectal neoplasia or change in bowel habits, we hypothesize that the diagnostic yield of complete colonoscopy will be low. The purpose of this study was to determine whether complete colonoscopy is necessary in the evaluation of patients with "outlet" rectal bleeding.Information for all patients undergoing colonoscopy by a single endoscopist was prospectively recorded. Before each colonoscopy, a complete history, including indication for the examination, was obtained. Using standard definitions, patients with outlet bleeding, suspicious bleeding, hemorrhage, and occult bleeding were accessed and the findings of their colonoscopies were analyzed. Institutional permission was obtained.A total of 9,098 patients had colonoscopy recorded in the database, and 703 had the indication of outlet bleeding, 251 suspicious bleeding, 204 occult bleeding, and 67 hemorrhage. Of the patients with outlet bleeding, only 47 (6.7 percent) had significant lesions on colonoscopy (adenomas1 cm, villous adenomas, cancer in situ, or invasive cancer). By contrast a greater number of significant lesions were present in patients with all other types of bleeding (17.2 percent; P0.001). The incidence of invasive cancer was significantly lower in the outlet bleeding group compared with other types of bleeding (1 vs. 3.6 percent; P0.01). Patients with outlet bleeding were much less likely than patients with other bleeding to have isolated right-sided colonic pathology. Younger patients with outlet bleeding have a particularly low yield on colonoscopy. In 182 patients younger than aged 50 years with outlet bleeding, only 3 (1.6 percent) had adenomas1 cm and no invasive cancers were detected.In patients with classic outlet bleeding, the yield of a complete diagnostic colonoscopy is low. If the history is classic for outlet bleeding and no other indication for colonoscopy exists, flexible sigmoidoscopy is enough to exclude significant pathology.

Acute ischemic proctitis is an extremely rare clinical entity. It is mainly described in patients with significant atherosclerotic and cardiac risk factors who present with lower gastrointestinal symptoms in the setting of hemodynamic instability. Previous reports of ischemic proctitis suggest that rectal resection is not necessary in the treatment of this disease. We present four cases of acute ischemic proctitis that required complete proctectomy. All patients had large vessel atherosclerosis with rectal bleeding and sepsis as the presenting signs and symptoms. Three of four patients underwent complete proctectomy as the initial procedure. The fourth patient underwent complete proctectomy five days after the initial intervention. Two of four patients survived and were ultimately discharged from the hospital. A third patient recovered from surgery but ultimately died of respiratory complications. Only the patient who was initially treated by subtotal proctectomy died as the result of the disease. Although ischemic necrosis of the rectum is rare, complete proctectomy may be necessary to save the patient's life.

Solitary rectal ulcer syndrome is an uncommon and often underdiagnosed condition that usually presents with hematochezia, mucous discharge, and tenesmus. Its etiology is unknown but it seems related to excessive straining with defecation. Prolonged efforts force the anterior rectal mucosa into the anal canal with strangulation and appearance of congestion, edema, and ulceration. Histologic findings (fibromuscular obliteration of lamina propria and disorientation of muscle fibers) are characteristic, which helps to differentiate these lesions from other rectal entities. Although solitary rectal ulcer syndrome is rarely reported in children, it must be suspected in patients with rectal discharge of blood and mucus and previous disorders of evacuation. We present three children (aged 9, 10, and 14 years) with solitary rectal ulcer syndrome that had presented with rectal bleeding. A careful inquiry about evacuation habits and a high index of suspicion in children presenting with hematochezia helps to diagnose this possibly unrecognized or misdiagnosed entity in children. Endoscopy and histologic examination confirms this condition.

Postoperative pain is the main adverse effect of formal hemorrhoidectomy. A new technique based on Doppler-guided ligation of the terminal branches of the superior hemorrhoidal artery was introduced in 1995 as an alternative to hemorrhoidectomy. The authors report a preliminary experience with this procedure. The Doppler-guided hemorrhoidal artery ligation technique uses a special proctoscope bearing a Doppler transducer that allows identification and suture ligation of the hemorrhoidal arteries. Sixty-eight consecutive patients (mean age, 48 years; range, 21–74 years) with Grade 3 hemorrhoids were treated. Intraoperative discomfort was measured by a visual analog scale (1–10) and resulted in a mean score of 2.3 (range, 1.3–2.8). Only 38 percent of patients required postoperative analgesia. Patients were examined at 1 week, 1 month, and 3 months and every 6 months thereafter. The mean follow-up was 11 (range, 3–18) months. Bleeding resolved in 91 percent of patients, pain in 73 percent, and prolapse in 94 percent. Complications were recorded in five patients and included persistent pain for more than two days in two patients (3 percent), swelling and thrombosis of one of the hemorrhoids in two patients (3 percent), and a secondary hemorrhage in one patient (1.5 percent). Doppler-guided ligation of the hemorrhoidal artery is a safe and effective alternative to hemorrhoidectomy and is associated with minimal discomfort and low risk of complications.

We report the case of 65-year-old man who developed massive rectal bleeding associated with the use of a fecal collecting device: the Flexi-Seal Fecal Management System. A colonoscopy showed an acute laceration of the anterior rectal wall mucosa, 6 cm from the anal verge, with active bleeding. The tear was most likely the result of an acute event, such as sudden movement of the device within the rectum or trauma sustained during insertion. Massive transfusion was required, and surgical endoscopic treatment was necessary to ensure hemostasis. This is, to our knowledge, the first such case to be reported.

INTRODUCTION: The laparoscopic approach in suture rectopexy with sigmoid resection is appealing as surgery is mainly confined to the pelvis. METHODS: The procedure is performed in modified lithotomy position using five trocars. In the case reported, the inferior mesenteric artery is divided distally to the left colic artery branch. The sigmoid colon is mobilized medially and may be mobilized laterally up to the descending colon, depending on the extent of resection. The splenic flexure remains in place. The rectum is mobilized from the presacral fascia down to the pelvic floor, sparing the hypogastric nerves. The rectum is transected in its upper third and the colonic stump pulled outside after enlarging the left lower abdominal incision to a length of 5 cm. The colorectal anastomosis is established intracorporeally in a double-stapling technique. Three 2-0 braided nonabsorbable sutures are placed to attach the right lateral stalks of the rectum to the presacral fascia. Proctoscopic examination has to ensure that there is no luminal compromise or air leakage. RESULTS: The videotape reports about a 37-year-old male patient with a rectal prolapse of 8 cm in length. First symptoms had occurred in childhood. He reported about temporary constipation and repeated rectal bleeding. During surgery, an elongated sigmoid was found. Laparoscopic sigmoid resection and suture rectopexy were carried out. There were no intraoperative or postoperative complications. The patient was discharged from the hospital on the sixth postoperative day. CONCLUSION: Laparoscopic resection rectopexy is safely feasible as a minimally-invasive treatment option for rectal prolapse.

PURPOSE: This article describes the use of intrarectal formalin to treat intractable rectal bleeding from pelvic malignancy. METHODS: Case reports of two patients with intractable rectal bleeding from pelvic malignancy are described. RESULTS: In both cases, treatment with intrarectal formalin stopped the rectal bleeding. CONCLUSION: Formalin instillation into the rectum is an invaluable technique when one is faced with rectal hemorrhage from inoperable pelvic tumors.

A case of exsanguinating rectal and retroperitoneal hemorrhage resulting from a ruptured inferior gluteal artery aneurysm is presented. Transcatheter embolization of Gelfoam and a Gianturco coil device resulted in the control of bleeding and proved to be a life-saving measure in a patient who was a poor surgical candidate.

Significant lower gastrointestinal hemorrhage from an ulcerated appendiceal stump after remote uncomplicated appendectomy is reported. The diagnosis was established by pathologic examination of the surgical specimen, but the area of bleeding was localized by preoperative colonoscopy. Angiography or isotope scan might also have identified the site of more rapid bleeding.