Ischemic Proctitis: Case Series and Literature Review

Abstract

Ischemic injury to the rectum is rare owing to its rich vascular supply, and is seldom seen in clinical practice. Risk factors include major vascular occlusive disease, disruption of collateral circulation, and low flow state. It is of paramount importance to diagnose this entity early in its course. Although CT scan can suggest the diagnosis and identify other causes of clinical deterioration, colonoscopy remains the key test in diagnosing and determining the extent of ischemic change. Endoscopic findings and the overall clinical picture determine patient management. Treatment is nonoperative for nongangrenous ischemic proctocolitis, whereas surgery is necessary for gangrenous, transmural rectal ischemia. Over a 20-year period, a retrospective review of cases of acute rectal ischemia were analyzed. Aortoiliac occlusive disease accounted for nearly one-half the cases (7/15), and 40 per cent (6/15) was secondary to a low flow state. In our series, two-thirds of the cases involved transmural necrosis of the rectal wall (40% mortality) and the remaining one-third presented with patchy ischemic changes (20% mortality).

Acute rectal ischemia following failed uterine artery embolization and emergency hysterectomy for postpartum hemorrhage

“…Acute rectal ischemia is rare. The rectum is often spared in cases of ischemic colitis owing to its abundant collateral blood supply [1]. Uterine artery embolization is an effective second‐line therapy used to control massive postpartum hemorrhage when medical treatment has failed to stop the bleeding [2,3].…”

“…Acute ischemic colitis commonly occurs in the splenic, descending, and sigmoid colon. The rectum is involved in less than 2% of all cases [1]. Ischemic proctitis is most commonly described in 70‐year‐old men (75%) and secondary to radiotherapy, severe aortoiliac occlusive disease, tumor encasement of the rectum, or prior vascular surgery with interruption of the collateral blood supply [1,4].…”

“…The rectum is involved in less than 2% of all cases [1]. Ischemic proctitis is most commonly described in 70‐year‐old men (75%) and secondary to radiotherapy, severe aortoiliac occlusive disease, tumor encasement of the rectum, or prior vascular surgery with interruption of the collateral blood supply [1,4]. In the present case, the transitory subischemic conditions in the pelvic area induced by embolotherapy in a patient with hypotension and in hemorrhagic shock may explain the occurrence of acute ischemic proctitis.…”

“…Diagnosis of acute ischemic proctitis may be indicated by pelvic pain associated with diarrhea and lax or absent anal sphincter tone in a patient with a major illness or hemodynamic disturbance [1,4]. It requires pelvic imaging (computerized tomography, color flow Doppler imaging, angiography, or MRI) and a definitive diagnosis is obtained by proctosigmoidoscopy [1]. Adequate management of acute ischemic proctitis is controversial, depends on the clinical status of the patient, and on the assessment of the degree of ischemia at proctosigmoidoscopy.…”

“…Conservative management with antibiotics is appropriate for uncomplicated acute ischemic proctitis. Patients with more severe degrees of rectal ischemia may develop bowel perforation necessitating a proctectomy or colonic diversion [1,4].…”