Rectal bleeding is a well-known adverse event related to transrectal prostate biopsy, with a frequency ranging from 0 % to 37 % 1 . Most bleeding is mild and resolves with conservative management. Severe bleeding, affecting up to 1 % of patients undergoing transrectal prostate biopsy, is uncommon but can be life-threatening 2 . Rectal bleeding typically occurs immediately after the biopsy. Delayed-onset bleeding is rare although several cases have been reported 3 4 . Herein, we present a case of delayed-onset severe bleeding after transrectal prostate biopsy, which was successfully treated with endoscopic clipping ( Video 1 ).
Video 1 Endoscopic diagnosis and treatment for delayed-onset rectal bleeding after transrectal prostate biopsy presenting as a rectal Dieulafoy’s lesion.
A 77-year-old man with a high prostate-specific antigen level underwent transrectal prostate biopsy. The patient developed hematochezia and hemorrhagic shock 5 days after the biopsy. The blood test revealed a drop in the hemoglobin level from 13.6 to 8.2 g/dL. The patient was referred to our department because digital compression did not achieve hemostasis. Emergency colonoscopy revealed a massive fresh clot in the rectum ( Fig. 1 ), and we identified a pulsatile large-caliber vessel on the anterior wall of the rectum ( Fig. 2 ). The vessel was surrounded by normal mucosa, which confirmed the diagnosis of Dieulafoy’s lesion ( Fig. 3 ). We performed endoscopic hemostasis with clipping ( Fig. 4 ). Active bleeding was observed when we placed the first clip; however, a total of three clips achieved hemostasis. The patient had no further bleeding and was discharged without additional interventions.
Fig. 1 .
Massive fresh clot in the rectum.
Fig. 2.
Forward view of a pulsatile, large-caliber vessel on the anterior wall of the rectum.
Fig. 3.
Retroflex view of the protruding vessel surrounded by normal mucosa.
Fig. 4.
Endoscopic image after endoscopic clipping for hemostasis.
Interestingly, in this case, delayed-onset bleeding presented as Dieulafoy’s lesion. The mucosal defect created by the biopsy needle might have caused the exposure of the underlying submucosal artery to the rectal lumen. A recent case-based systematic review reported the efficacy of endoscopic therapy for severe bleeding after transrectal prostate biopsy 5 . In addition, this case highlights the importance of early endoscopic intervention to improve the patient’s outcome in such cases.
Endoscopy_UCTN_Code_TTT_1AQ_2AZ
Acknowledgment
We would like to thank Editage ( www.editage.jp ) for English language editing.
Footnotes
Competing interests The authors declare that they have no conflict of interest.
Endoscopy E-Videos : https://eref.thieme.de/e-videos .
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available. This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
References
- 1.Quinlan M R, Bolton D, Casey R G. The management of rectal bleeding following transrectal prostate biopsy: a review of the current literature. Can Urol Assoc J. 2018;12:E146–E153. doi: 10.5489/cuaj.4660. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Brullet E, Guevara M C, Campo R et al. Massive rectal bleeding following transrectal ultrasound-guided prostate biopsy. Endoscopy. 2000;32:792–795. doi: 10.1055/s-2000-7709. [DOI] [PubMed] [Google Scholar]
- 3.Ustündağ Y, Yeşilli C, Aydemir S et al. A life-threatening hematochesia after transrectal ultrasound-guided prostate needle biopsy in a prostate cancer case presenting with lymphedema. Int Urol Nephrol. 2004;36:397–400. doi: 10.1007/s11255-004-8868-x. [DOI] [PubMed] [Google Scholar]
- 4.Ando T, Watanabe K, Mizusawa T et al. Late-onset rectal bleeding with hemorrhagic shock after transrectal prostate needle biopsy. Urol Case Rep. 2018;21:41–43. doi: 10.1016/j.eucr.2018.08.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Malik A, Ishtiaq R, Goraya M HN.Endoscopic therapy in the management of patients with severe rectal bleeding following transrectal ultrasound-guided prostate biopsy: a case-based systematic review J Investig Med High Impact Case Rep 2021923247096211013206. 10.1177/23247096211013206 [DOI] [PMC free article] [PubMed] [Google Scholar]