{ "slug": "why-am-i-pooping-blood-no-pain", "question": "Why am I pooping blood with no pain?", "shortTitle": "Painless Blood in Stool", "clinicalQuestion": "In adults presenting with painless rectal bleeding or blood-streaked/bloody stool, what are the most common underlying causes, and how often does this symptom indicate colorectal cancer or another serious condition?", "pico": { "population": "Adults with painless hematochezia (blood in or on the stool, or blood when wiping, without pain)", "intervention": "Clinical evaluation of painless rectal bleeding (history, examination, anoscopy/colonoscopy)", "comparator": "No evaluation or evaluation for painful rectal bleeding", "outcomes": [ "Diagnosis distribution (hemorrhoids, anal fissure, diverticulosis, colorectal cancer, other)", "Proportion found to have colorectal cancer or advanced neoplasia", "Proportion found to have no identifiable cause", "Need for colonoscopy based on age and risk factors", "Rate of missed cancer diagnosis without workup" ] }, "category": "bowel-function", "relatedConditions": [ "hemorrhoids", "anal-fissure", "colorectal-cancer", "diverticulosis", "rectal-bleeding" ], "relatedTreatments": [], "relatedEvidence": [], "bottomLine": { "verdict": "Painless blood in your stool is usually caused by a common, treatable problem like hemorrhoids, diverticulosis (small pouches in the colon), or a rectal ulcer — but in a small number of people it turns out to be cancer or another serious condition, and the studies available cannot tell you which one applies to you without an exam.", "detail": "A large community survey found that only 1 in 709 people who reported rectal bleeding was later diagnosed with colorectal cancer. A separate, larger study of people sick enough to be hospitalized for bleeding found a cause on colonoscopy in nearly 95% of cases — most often diverticulosis, rectal ulcers, hemorrhoids, or abnormal blood vessels. These two studies looked at different groups of people and don't agree on how worrying the symptom usually is, which is why the certainty here is low. Case reports also describe rare but serious causes — including cancer, bowel tissue death, and damage from certain medications — found when painless bleeding was investigated.", "studyIds": [ "pmid:34388140", "pmid:23578119", "pmid:24742083", "pmid:21766771", "pmid:23769256", "pmid:20642975" ] }, "strength": { "level": "very-low", "why": "Only observational evidence addresses this question (4 studies). The studies disagree with one another, so the overall certainty is lower than any single one of them.", "override": null }, "direction": { "level": "harm-signal", "why": "7 studies reported harm or tissue damage, including laboratory evidence.", "override": null }, "counts": { "recordsRetrieved": 110, "recordsScreened": 110, "included": 104, "rcts": 4, "systematicReviews": 1, "observational": 7, "participants": 21122, "yearFrom": 1976, "yearTo": 2026, "registeredTrialsWithoutResults": 0 }, "excluded": [], "outcomes": [ { "name": "Proportion found to have colorectal cancer or advanced neoplasia", "status": "insufficient", "note": "In a large community survey, only 1 in 709 people with rectal bleeding was diagnosed with colorectal cancer. No large study has reported this figure specifically for painless bleeding in a hospital or high-risk setting, so this number may not apply to everyone.", "studyIds": [ "pmid:23578119" ] }, { "name": "Proportion found to have no identifiable cause", "status": "insufficient", "note": "In one large hospital study, colonoscopy found a cause in 94.9% of adults with rectal bleeding, meaning roughly 1 in 20 had no cause identified. A smaller pediatric study found a handful of children with mild painless bleeding stayed undiagnosed.", "studyIds": [ "pmid:34388140", "pmid:6606026" ] }, { "name": "Need for colonoscopy based on age and risk factors", "status": "not-studied", "note": "No study has directly tested or compared different age- or risk-based thresholds for ordering a colonoscopy after painless rectal bleeding. One review states that people with risk factors for colorectal cancer, such as adults over 50, should have a colonoscopy to rule out cancer even if hemorrhoids are seen on exam, but this is a general recommendation rather than a result from a comparative study of thresholds.", "studyIds": [ "pmid:24742083" ] }, { "name": "Rate of missed cancer diagnosis without workup", "status": "not-studied", "note": "No study measured how often a serious cause is missed in people whose painless bleeding is never investigated.", "studyIds": [] } ], "benefits": [ { "text": "When painless rectal bleeding is investigated with colonoscopy, doctors find a specific, explainable cause in the large majority of cases — most often diverticulosis, a rectal ulcer, hemorrhoids, or abnormal blood vessels.", "studyIds": [ "pmid:34388140" ] }, { "text": "In a large community survey, most people who reported rectal bleeding did not turn out to have colorectal cancer.", "studyIds": [ "pmid:23578119" ] }, { "text": "Hemorrhoids, a very common and usually treatable cause of bright red painless bleeding, often improve with simple measures like fiber, stool softeners, or minor procedures.", "studyIds": [ "pmid:33087033", "pmid:24742083", "pmid:21766771" ] } ], "limitations": [ { "text": "Almost all of the detailed evidence on specific causes — tumors, hemangiomas, Meckel's diverticulum, endometriosis, and more — comes from single-patient case reports, which cannot show how common any one of these causes actually is.", "studyIds": [ "pmid:42430297", "pmid:40627878", "pmid:40525030", "pmid:38646340", "pmid:37464856", "pmid:38477093", "pmid:36304634", "pmid:36211606", "pmid:34252643", "pmid:33397878", "pmid:31275778", "pmid:23769256", "pmid:19366548", "pmid:18472711", "pmid:18330577", "pmid:17266878", "pmid:10596577", "pmid:1402312" ] }, { "text": "The two largest studies on this question looked at different groups — one surveyed anyone in the community who noticed bleeding, the other studied people sick enough to be hospitalized for it — so their findings can't be combined into one answer.", "studyIds": [ "pmid:34388140", "pmid:23578119" ] }, { "text": "No randomized trial has tested how painless rectal bleeding should be worked up; every study here is observational, so other unmeasured differences between patients could affect the results.", "studyIds": [ "pmid:34388140", "pmid:23578119" ] } ], "risks": [ { "text": "In a small case series of three high-risk elderly patients with significant other health problems, routine anorectal procedures (glycerin enemas or anorectal pressure testing) were followed by sudden, massive, painless bleeding severe enough to need emergency treatment. It is not known how often this happens or whether the risk is similar in people without serious underlying illness.", "studyIds": [ "pmid:41904412" ], "severity": "serious" }, { "text": "A bleeding rectal ulcer found during investigation can be serious in frail patients: in one case report, bleeding continued despite treatment and the patient later died of organ failure.", "studyIds": [ "pmid:40506688" ], "severity": "serious" }, { "text": "Common painkillers (NSAIDs) and a phosphate-binding drug used in kidney disease (sevelamer) have each been linked, in case reports, to ulcers that damaged the bowel lining and caused painless bleeding.", "studyIds": [ "pmid:24829679", "pmid:26157856" ], "severity": "serious" }, { "text": "Rectal cancer causing painless bleeding has, in a rare case report, been linked to a severe clotting complication that proved fatal.", "studyIds": [ "pmid:23769256" ], "severity": "serious" }, { "text": "Bowel tissue death from a blocked blood supply is a rare but life-threatening cause of painless bleeding described in one case report; it was only diagnosed after the patient died.", "studyIds": [ "pmid:20642975" ], "severity": "serious" }, { "text": "Surgery for hemorrhoids (a stapling procedure) caused bleeding during the operation in nearly half of patients in one study, and about 1 in 4 needed to be readmitted to hospital for bleeding afterward.", "studyIds": [ "pmid:16024315" ], "severity": "serious" } ], "whyPeopleTryIt": [ { "text": "Bleeding without pain feels less alarming, so it's easy to assume it isn't serious." }, { "text": "Hemorrhoids are so common that many people assume that must be the cause without getting checked." }, { "text": "Embarrassment about rectal symptoms makes people put off seeing a doctor." }, { "text": "The bleeding often stops on its own for a while, which can feel like reassurance that nothing is wrong." } ], "keyStudies": [ "pmid:34388140", "pmid:23578119", "pmid:24742083", "pmid:32358354", "pmid:23769256", "pmid:20642975" ], "studies": [ { "id": "pmid:42430297", "pmid": "42430297", "doi": "10.12659/AJCR.951726", "nctId": null, "pmcid": "PMC13367095", "title": "An 18-Year-Old Man with Bleeding From a Meckel's Diverticulum of the Terminal Ileum Diagnosed by 99mTc-Pertechnetate Scintigraphy (Meckel's Scan)", "firstAuthor": "Alswiket", "multipleAuthors": true, "journal": "Am J Case Rep", "year": 2026, "design": "case-series", "n": 1, "nField": "reported", "population": "18-year-old man with sudden painless rectal bleeding", "intervention": "99mTc-pertechnetate scintigraphy (Meckel's scan) for diagnosis, followed by surgical removal", "comparator": "other diagnostic tests (CT scan, colonoscopy, endoscopy, capsule endoscopy) that failed to find the cause", "primaryOutcome": "finding the source of the bleeding", "result": "the Meckel's scan found a Meckel's diverticulum after other tests missed it, and surgery removed it successfully", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how often this explains painless bleeding or how reliable the scan is in general.", "directness": "direct", "limitations": "only one patient; no comparison group; cannot say how common this cause is", "followUp": "", "plainFinding": "Rare bowel pouch caused bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42430297/", "sourceText": "BACKGROUND Meckel's diverticulum represents the most common congenital anomaly of the gastrointestinal tract in the pediatric population. Although it is rarely symptomatic, painless rectal bleeding is the most common manifestation among pediatric patients. In contrast, Meckel's diverticulum is considerably rare in adults, in whom intestinal obstruction and diverticulitis are more frequent complications than bleeding. When it is suspected, a Meckel's scan is the most sensitive and specific diagnostic tool. Surgical excision remains the treatment of choice for Meckel's diverticulum. This report describes the case of an 18-year-old man with bleeding from a Meckel's diverticulum of the terminal ileum diagnosed by 99mTc-pertechnetate scintigraphy (Meckel's scan). CASE REPORT We report the case of an 18-year-old male patient who presented to the emergency department with a 24-hour history of 4 episodes of fresh rectal bleeding, associated with dizziness, nausea, palpitations, and a loss of consciousness. The patient underwent an extensive diagnostic workup, including computed tomography scan, sigmoidoscopy, colonoscopy, esophagogastroduodenoscopy, and capsule endoscopy, none of which revealed any abnormalities. A Meckel's scan eventually confirmed the presence of a Meckel's diverticulum on day 4 of admission, followed by a successful laparoscopic segmental resection on day 10 of admission. CONCLUSIONS Meckel's diverticulum, a common etiology of lower gastrointestinal bleeding in pediatric patients, presents a diagnostic challenge in adults, requiring a heightened index of suspicion. Clinical suspicion should be raised in cases with inconclusive initial investigations, particularly in younger adults.", "provenance": [ { "field": "n", "quote": "the case of an 18-year-old male patient" }, { "field": "population", "quote": "18-year-old male patient who presented to the emergency department with a 24-hour history of 4 episodes of fresh rectal bleeding" }, { "field": "intervention", "quote": "A Meckel's scan eventually confirmed the presence of a Meckel's diverticulum on day 4 of admission, followed by a successful laparoscopic segmental resection on day 10 of admission." }, { "field": "comparator", "quote": "computed tomography scan, sigmoidoscopy, colonoscopy, esophagogastroduodenoscopy, and capsule endoscopy, none of which revealed any abnormalities" }, { "field": "primaryOutcome", "quote": "A Meckel's scan eventually confirmed the presence of a Meckel's diverticulum" }, { "field": "result", "quote": "A Meckel's scan eventually confirmed the presence of a Meckel's diverticulum on day 4 of admission, followed by a successful laparoscopic segmental resection on day 10 of admission." } ] }, { "id": "pmid:42290952", "pmid": "42290952", "doi": "10.1177/11795565261456425", "nctId": null, "pmcid": "PMC13260782", "title": "Schistosomal Colitis as an Uncommon Cause of Hematochezia in a School-Aged Boy: A Case Report", "firstAuthor": "Suleman", "multipleAuthors": true, "journal": "Clin Med Insights Pediatr", "year": 2026, "design": "case-series", "n": 1, "nField": "reported", "population": "a 9-year-old boy living in a region where schistosomiasis is common", "intervention": "oral Praziquantel (40 mg/kg)", "comparator": "none", "primaryOutcome": "resolution of painless rectal bleeding", "result": "the boy's bleeding improved after treatment with praziquantel", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether this treatment works in general.", "directness": "direct", "limitations": "only one patient was described, with no comparison group, so results may not apply to others.", "followUp": "", "plainFinding": "Painless bleeding from parasite infection, treated successfully.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42290952/", "sourceText": "Schistosomiasis is a neglected tropical disease with clinical presentations that vary depending on the species involved. Schistosomal colitis is a rare manifestation, with few cases documented in the literature. We report a case of a 9-year-old boy presenting with painless hematochezia and a history of residence in a schistosomiasis-endemic region. Colonoscopy revealed evidence of colitis, and histopathological examination of colon biopsy confirmed schistosomal ova with eosinophilic infiltration in the colonic mucosa. The patient responded well to treatment with oral Praziquantel (40 mg/kg). This case underscores the need for a high index of suspicion and the inclusion of tropical diseases in the differential diagnosis when evaluating patients with lower gastrointestinal bleeding, particularly in endemic areas. Pediatric schistosomal colitis in Africa represents a clinically significant yet often underdiagnosed manifestation of Schistosomiasis, highlighting the need for heightened awareness of its distinctive gastrointestinal presentations, diagnostic challenges, and implications for early intervention in children living in endemic regions.", "provenance": [ { "field": "n", "quote": "We report a case of a 9-year-old boy" }, { "field": "population", "quote": "a 9-year-old boy presenting with painless hematochezia and a history of residence in a schistosomiasis-endemic region" }, { "field": "intervention", "quote": "treatment with oral Praziquantel (40 mg/kg)" }, { "field": "comparator", "quote": "The patient responded well to treatment with oral Praziquantel (40 mg/kg)." }, { "field": "primaryOutcome", "quote": "presenting with painless hematochezia" }, { "field": "result", "quote": "The patient responded well to treatment with oral Praziquantel (40 mg/kg)." } ] }, { "id": "pmid:41904412", "pmid": "41904412", "doi": "10.1186/s12876-026-04769-7", "nctId": null, "pmcid": "PMC13151078", "title": "Life-threatening lower gastrointestinal bleeding after routine anorectal procedures: a case series and management implications", "firstAuthor": "Yin", "multipleAuthors": true, "journal": "BMC Gastroenterol", "year": 2026, "design": "case-series", "n": 3, "nField": "reported", "population": "elderly patients with health problems who had routine anorectal procedures", "intervention": "glycerin enemas or anorectal manometry (catheter/instrument procedures)", "comparator": "none", "primaryOutcome": "severe rectal bleeding after the procedure", "result": "all three patients had sudden, painless, massive rectal bleeding with major blood loss and instability, found to be caused by injury from the procedure in the distal rectum", "resultDirection": "harm", "quality": "very-low", "qualityWhy": "This is only three patient cases, so it cannot show how common this is or prove it applies broadly.", "directness": "direct", "limitations": "Very small case series of only 3 patients with no comparison group, so causality and frequency cannot be established.", "followUp": "", "plainFinding": "Enemas caused severe rectal bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41904412/", "sourceText": "BACKGROUND: This case series characterizes enema- and catheter-induced rectal injuries as an underrecognized iatrogenic cause of life-threatening lower gastrointestinal bleeding (LGIB). By focusing on elderly, high-risk patients, we highlight the diagnostic complexities and management strategies associated with these routine yet potentially catastrophic anorectal procedures. METHODS: We analyzed three cases of high-risk elderly patients who experienced acute, massive hemorrhage following routine anorectal procedures, specifically glycerin enemas and anorectal manometry. To contextualize these findings, we performed a narrative literature review of the PubMed and Web of Science databases to identify recurring clinical characteristics and predisposing factors associated with these iatrogenic rectal injuries. RESULTS: All three elderly patients with significant comorbidities experienced sudden, painless, massive hematochezia following routine anorectal procedures. Standard anoscopy failed to localize the bleeding source due to obscuration by extensive blood clots. However, emergency colonoscopy without bowel preparation successfully identified and treated bleeding foci in the distal rectum (3-4 cm from the anal verge). Clinically, the patients demonstrated profound hemoglobin drops ranging from 10 to 80 g/L (nadir: 59 g/L) and severe hemodynamic instability (lowest blood pressure [BP]: 89/56 mmHg; Heart rate[HR]: 120 bpm). Two patients required massive blood transfusions, receiving up to 13 units of red blood cells and 1,350 mL of fresh frozen plasma to maintain stability. Notably, all three patients required Intensive care unit (ICU) admission for intensive monitoring and resuscitation. Common risk factors identified included advanced age, prolonged bed rest, and underlying coagulopathy. CONCLUSION: In frail, bedridden patients, even routine anorectal procedures such as enema administration or catheterization can trigger catastrophic, life-threatening hemorrhage. While instrumentation is the primary trigger, clinical outcomes depend on recognizing potential mucosal vulnerability. The key to survival lies in early risk stratification, maintaining a high index of clinical suspicion regarding recent procedural history, and proceeding directly to emergency colonoscopy to identify and treat hidden bleeding sources in the distal rectum. Such vigilance is not merely best practice-it is life-saving and should be formally integrated into clinical guidelines to enhance safety for high-risk populations.", "provenance": [ { "field": "n", "quote": "We analyzed three cases of high-risk elderly patients" }, { "field": "population", "quote": "high-risk elderly patients who experienced acute, massive hemorrhage following routine anorectal procedures, specifically glycerin enemas and anorectal manometry" }, { "field": "intervention", "quote": "routine anorectal procedures, specifically glycerin enemas and anorectal manometry" }, { "field": "comparator", "quote": "Standard anoscopy failed to localize the bleeding source" }, { "field": "primaryOutcome", "quote": "sudden, painless, massive hematochezia following routine anorectal procedures" }, { "field": "result", "quote": "All three elderly patients with significant comorbidities experienced sudden, painless, massive hematochezia following routine anorectal procedures." } ] }, { "id": "pmid:41837035", "pmid": "41837035", "doi": "10.1097/RC9.0000000000000291", "nctId": null, "pmcid": "PMC12981848", "title": "Acute hemorrhagic rectal ulcer after cardiac surgery: a case report", "firstAuthor": "Motoyoshi", "multipleAuthors": true, "journal": "Int J Surg Case Rep", "year": 2026, "design": "case-series", "n": 2, "nField": "reported", "population": "men recovering from cardiac surgery with diabetes and kidney dialysis", "intervention": "endoscopic treatment with heat cautery and clipping for bleeding rectal ulcers", "comparator": "", "primaryOutcome": "stopping the bleeding and recovery", "result": "both patients had painless bloody stools and shock from rectal ulcers, and recovered after repeated endoscopic treatment", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is just two patients described after the fact, so it cannot tell you how common this is or what causes it in general", "directness": "indirect", "limitations": "only two patients, both with major underlying illness and recent major surgery, so unlikely to reflect a general case of painless rectal bleeding", "followUp": "within 1 week postoperatively", "plainFinding": "Rare bleeding ulcer after heart surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41837035/", "sourceText": "INTRODUCTION: Gastrointestinal (GI) bleeding is still a rare but serious complication after cardiac surgery, with a reported mortality rate of 30%-50%. Acute hemorrhagic rectal ulcer (AHRU) is an uncommon cause of massive lower GI bleeding, typically seen in bed-ridden or critically ill patients, but has not previously reported following cardiac surgery. PRESENTATION OF CASE: We report two cases of AHRU occurring in the intensive care unit after cardiac surgery. The first patient, a 64-year-old man on chronic hemodialysis for diabetic nephropathy, and the second, a 71-year-old man with similar comorbidities, both developed sudden, painless hematochezia and hemorrhagic shock within 1 week postoperatively. Endoscopy revealed ulcerative lesions 3-10 cm above the dentate line. Hemostasis was achieved with heat probe cautery and clipping; both patients required repeated endoscopic interventions but ultimately recovered and were discharged. DISCUSSION: The pathogenesis of AHRU may involve ischemic mucosal injury related to diabetes, hemodialysis, anticoagulation, and prolonged supine positioning. Early mobilization and careful management of anticoagulation may reduce risk. Given the high recurrence rate of AHRU, scheduled second-look endoscopy may be beneficial. CONCLUSIONS: This is the first report of AHRU following cardiac surgery. Prompt bedside endoscopic intervention, intensive management of hemorrhagic shock, and early postoperative rehabilitation are essential for favorable outcomes. Development of a preventive care bundle for high-risk postoperative patients is recommended.", "provenance": [ { "field": "population", "quote": "The first patient, a 64-year-old man on chronic hemodialysis for diabetic nephropathy, and the second, a 71-year-old man with similar comorbidities" }, { "field": "intervention", "quote": "Hemostasis was achieved with heat probe cautery and clipping" }, { "field": "primaryOutcome", "quote": "both patients required repeated endoscopic interventions but ultimately recovered and were discharged" }, { "field": "result", "quote": "both developed sudden, painless hematochezia and hemorrhagic shock within 1 week postoperatively" }, { "field": "n", "quote": "We report two cases of AHRU occurring in the intensive care unit after cardiac surgery." }, { "field": "followUp", "quote": "within 1 week postoperatively" } ] }, { "id": "pmid:41837015", "pmid": "41837015", "doi": "10.1097/RC9.0000000000000129", "nctId": null, "pmcid": "PMC12981821", "title": "Exsanguinating jejunal Dieulafoy's hemorrhage: how failed embolization guided life-saving resection - a case report", "firstAuthor": "Hu", "multipleAuthors": false, "journal": "Int J Surg Case Rep", "year": 2026, "design": "case-series", "n": 1, "nField": "reported", "population": "31-year-old woman with sudden severe rectal bleeding and shock, no prior health problems", "intervention": "Surgery to remove the bleeding part of the small intestine (jejunum), after embolization failed", "comparator": "Attempted artery embolization (blocking the bleeding vessel) before surgery", "primaryOutcome": "Stopping the bleeding and patient recovery", "result": "Embolization failed to stop the bleeding, but surgical removal of the lesion stopped it and the patient recovered and went home 5 days later", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how often this treatment works for others.", "directness": "direct", "limitations": "Only one patient described, no comparison group, so findings may not generalize.", "followUp": "", "plainFinding": "Surgery stopped life-threatening bleeding lesion.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41837015/", "sourceText": "INTRODUCTION AND IMPORTANCE: Dieulafoy's lesion is a rare but severe cause of gastrointestinal bleeding. It is characterized by an aberrant submucosal arteriole eroding through the gastrointestinal mucosa, typically causing sudden, painless, and massive gastrointestinal hemorrhage that may present with intermittent, recurrent bleeding episodes. We report a case of hemorrhagic shock secondary to massive gastrointestinal bleeding caused by a jejunal Dieulafoy's lesion. CASE PRESENTATION: A 31-year-old female without significant medical comorbidities acutely developed recurrent, high-volume hematochezia and hypotensive shock. She was hemodynamically unstable with a hemoglobin level of 35 g/l upon admission. After hemodynamic stabilization and transfusion, endoscopy failed to localize the bleeding source, which was later identified in the jejunum by angiography. Selective arterial embolization was implemented but failed to achieve hemostasis. Consequently, exploratory laparotomy with segmental jejunal resection of the Dieulafoy's lesion was performed. The patient demonstrated satisfactory recovery and was discharged on the fifth postoperative day. CLINICAL DISCUSSION: Jejunal Dieulafoy's lesion is an exceedingly rare cause of gastrointestinal bleeding, accounting for merely 1% of all Dieulafoy's lesions. Diagnosis is challenging due to the inaccessibility of jejunum with conventional endoscopy and the intermittent nature of hemorrhage. Angiographic embolization is effective for active bleeding when endoscopic therapy fails. Surgery remains an option when other interventions are unsuccessful, particularly in hemodynamically unstable patients. CONCLUSION: Jejunal Dieulafoy's lesion, though rare, is a potentially life-threatening cause of gastrointestinal hemorrhage that demands prompt diagnosis and intervention. A multidisciplinary approach - combining endoscopic therapy, angiography, and surgery - significantly enhances clinical outcomes.", "provenance": [ { "field": "population", "quote": "A 31-year-old female without significant medical comorbidities acutely developed recurrent, high-volume hematochezia and hypotensive shock." }, { "field": "intervention", "quote": "exploratory laparotomy with segmental jejunal resection of the Dieulafoy's lesion was performed" }, { "field": "comparator", "quote": "Selective arterial embolization was implemented but failed to achieve hemostasis." }, { "field": "primaryOutcome", "quote": "The patient demonstrated satisfactory recovery and was discharged on the fifth postoperative day." }, { "field": "result", "quote": "Selective arterial embolization was implemented but failed to achieve hemostasis. Consequently, exploratory laparotomy with segmental jejunal resection of the Dieulafoy's lesion was performed. The patient demonstrated satisfactory recovery and was discharged on the fifth postoperative day." }, { "field": "n", "quote": "A 31-year-old female" } ] }, { "id": "pmid:41358171", "pmid": "41358171", "doi": "10.3748/wjg.v31.i43.111906", "nctId": null, "pmcid": "PMC12678946", "title": "Utilizing the EyeMax direct visualization system for the treatment of colonic diverticular bleeding: A case report", "firstAuthor": "Han", "multipleAuthors": true, "journal": "World J Gastroenterol", "year": 2025, "design": "case-series", "n": 1, "nField": "reported", "population": "70-year-old man with sudden painless rectal bleeding", "intervention": "colonoscopy using the EyeMax direct visualization system to find and treat the bleeding", "comparator": "none", "primaryOutcome": "whether the bleeding source was found and stopped", "result": "the bleeding diverticulum was located and bleeding stopped, patient discharged a week later", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether this approach generally works better than standard care.", "directness": "direct", "limitations": "only one patient described; no comparison group", "followUp": "", "plainFinding": "Bleeding pouch found and stopped.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41358171/", "sourceText": "BACKGROUND: Colonic diverticular bleeding is a significant cause of acute overt lower gastrointestinal hemorrhage. Colonoscopy is commonly performed in patients with colonic diverticular bleeding to identify and treat the source of bleeding, which is crucial for effective management. CASE SUMMARY: We present the case of a 70-year-old male with acute painless hematochezia. Colonoscopy showed active bleeding originating from a diverticulum, and the EyeMax direct visualization system was used in the treatment of the colonic diverticular bleeding. No further evidence of bleeding was observed at the end of the procedure. The patient was discharged from hospital on the seventh day. CONCLUSION: The EyeMax system proved advantageous in localizing the bleeding diverticulum, thereby facilitating successful hemostatic measures.", "provenance": [ { "field": "population", "quote": "a 70-year-old male with acute painless hematochezia" }, { "field": "intervention", "quote": "the EyeMax direct visualization system was used in the treatment of the colonic diverticular bleeding" }, { "field": "comparator", "quote": "Colonoscopy showed active bleeding originating from a diverticulum, and the EyeMax direct visualization system was used in the treatment of the colonic diverticular bleeding." }, { "field": "primaryOutcome", "quote": "No further evidence of bleeding was observed at the end of the procedure." }, { "field": "result", "quote": "No further evidence of bleeding was observed at the end of the procedure. The patient was discharged from hospital on the seventh day." }, { "field": "n", "quote": "a 70-year-old male" } ] }, { "id": "pmid:41332049", "pmid": "41332049", "doi": "10.1016/j.ijscr.2025.112025", "nctId": null, "pmcid": "PMC12552957", "title": "Rectal Arteriovenous Malformations: A case report of a rare cause of Lower Gastrointestinal Bleeding", "firstAuthor": "Mureb", "multipleAuthors": true, "journal": "Int J Surg Case Rep", "year": 2025, "design": "case-series", "n": 1, "nField": "reported", "population": "a 37-year-old man with blood in urine and recurring rectal bleeding", "intervention": "angioembolization procedures followed by surgery (laparoscopic low anterior resection with diverting ileostomy)", "comparator": "no comparator, single patient followed over time", "primaryOutcome": "control of rectal bleeding and resolution of anemia", "result": "repeated angioembolization did not stop the bleeding, and surgery was ultimately needed", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether treatments generally work.", "directness": "direct", "limitations": "only one patient described, no control group, and no standardized treatment guideline exists for this condition", "followUp": "", "plainFinding": "Rare vessel defect caused painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41332049/", "sourceText": "INTRODUCTION AND IMPORTANCE: Rectal arteriovenous malformation (AVMs) are a rare cause of lower gastrointestinal bleeding. These vascular anomalies, typically present at birth, can progress over time and often lead to significant clinical challenges. The lack of a standardized classification or treatment guidelines further complicate diagnosis and management. This case report aims to contribute to the understanding of rectal AVMs by detailing clinical presentation, diagnosis, and treatment strategies. CASE PRESENTATION: We present a case of a 37-year-old male with hematuria and recurrent rectal bleeding, diagnosed through a series of imaging studies, including CT scan and pelvic MRI. Despite undergoing multiple angioembolization procedures, the patient's symptoms persisted, leading to significant anemia and frequent emergency interventions. The decision was made to proceed with a laparoscopic low anterior resection with diverting ileostomy after a thorough discussion of the risk and benefits. CLINICAL DISCUSSION: This case underscore the complexity associated with diagnosis and managing rectal AVMs. The clinical presentation can vary significantly, and while symptoms often include painless rectal bleeding, many patients experience co-morbid condition due to chronic blood loss. Diagnosis typically involves imaging modalities, with angiography remaining the gold standard. Treatment options vary, and while angioembolization and endoscopic techniques may provide temporary relief, surgical intervention is often necessary for cases resistant to less invasive approaches. CONCLUSION: Rectal AVMs represent a rare but significant cause of gastrointestinal bleeding, necessitating a high index of suspicion for diagnosis. This case highlights the challenges in management and the need for further research to establish standardized treatment protocols.", "provenance": [ { "field": "n", "quote": "a 37-year-old male with hematuria and recurrent rectal bleeding" }, { "field": "population", "quote": "a 37-year-old male with hematuria and recurrent rectal bleeding, diagnosed through a series of imaging studies, including CT scan and pelvic MRI" }, { "field": "intervention", "quote": "Despite undergoing multiple angioembolization procedures, the patient's symptoms persisted, leading to significant anemia and frequent emergency interventions. The decision was made to proceed with a laparoscopic low anterior resection with diverting ileostomy" }, { "field": "comparator", "quote": "We present a case of a 37-year-old male" }, { "field": "primaryOutcome", "quote": "leading to significant anemia and frequent emergency interventions" }, { "field": "result", "quote": "Despite undergoing multiple angioembolization procedures, the patient's symptoms persisted, leading to significant anemia and frequent emergency interventions. The decision was made to proceed with a laparoscopic low anterior resection with diverting ileostomy after a thorough discussion of the risk and benefits." }, { "field": "primaryOutcome", "quote": "symptoms often include painless rectal bleeding" } ] }, { "id": "pmid:41245020", "pmid": "41245020", "doi": "10.1002/jpr3.70057", "nctId": null, "pmcid": "PMC12611578", "title": "An incidental finding of mesenteric hematoma in a patient with a new diagnosis of inflammatory bowel disease", "firstAuthor": "Brown", "multipleAuthors": true, "journal": "JPGN Rep", "year": 2025, "design": "case-series", "n": 1, "nField": "reported", "population": "a 10-year-old patient with painless rectal bleeding, newly diagnosed with ulcerative colitis", "intervention": "not applicable (case report describing diagnostic workup including exploratory surgery, CT angiography, and colonoscopy with biopsy)", "comparator": "", "primaryOutcome": "cause of painless rectal bleeding", "result": "the painless rectal bleeding was found to be due to an incidental mesenteric hematoma, occurring alongside a new diagnosis of ulcerative colitis, thought to result from inflammation causing microvascular bleeding or clotting", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single case report, so it cannot show how common this cause is or how it applies to other people.", "directness": "direct", "limitations": "only one patient described; management and outcome over time are not well established in the literature.", "followUp": "", "plainFinding": "Rare bleeding disorder found with colitis.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41245020/", "sourceText": "Mesenteric hematomas (MHs) are relatively rare and are characterized by localized bleeding in the mesenteric vascular tree presenting with abdominal pain, vomiting, abdominal distension, masses, and hypotension. We report a case of a MH which was incidentally found in a 10-year-old patient with a new diagnosis of ulcerative colitis (UC). This is the second-ever reported case of MH associated with inflammatory bowel disease to our knowledge, with the first being in an adult female with Crohn's disease. The patient presented with painless hematochezia with unknown etiology and underwent an exploratory laparotomy when a mesenteric hematoma was incidentally found. Further investigation including a computed tomography angiopathy showed findings concerning for inflammatory bowel disease and colonoscopy with biopsy confirmed a diagnosis of UC. We propose that the MH was a result of inflammation which caused microvascular bleeding/thrombotic events. Management strategies including follow-up of resolution is not well delineated in the literature.", "provenance": [ { "field": "population", "quote": "We report a case of a MH which was incidentally found in a 10-year-old patient with a new diagnosis of ulcerative colitis (UC)." }, { "field": "intervention", "quote": "underwent an exploratory laparotomy when a mesenteric hematoma was incidentally found" }, { "field": "primaryOutcome", "quote": "The patient presented with painless hematochezia with unknown etiology" }, { "field": "result", "quote": "We propose that the MH was a result of inflammation which caused microvascular bleeding/thrombotic events." }, { "field": "result", "quote": "colonoscopy with biopsy confirmed a diagnosis of UC" }, { "field": "n", "quote": "a 10-year-old patient" }, { "field": "limitations", "quote": "Management strategies including follow-up of resolution is not well delineated in the literature." } ] }, { "id": "pmid:40627878", "pmid": "40627878", "doi": "10.1016/j.ijscr.2025.111602", "nctId": null, "pmcid": "PMC12272464", "title": "Unveiling the hidden cause behind painless lower gastrointestinal bleeding in an adult - Meckel's Diverticulum: A case report", "firstAuthor": "Jha", "multipleAuthors": true, "journal": "Int J Surg Case Rep", "year": 2025, "design": "case-series", "n": 1, "nField": "reported", "population": "30-year-old man with painless rectal bleeding for 2 weeks, with similar episodes over 3 years", "intervention": "surgical removal of Meckel's Diverticulum (wedge resection)", "comparator": "no comparator (single case)", "primaryOutcome": "identification of the cause of painless rectal bleeding and resolution after treatment", "result": "CT scan found a Meckel's Diverticulum as the cause, and wedge resection was performed", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how common this cause is or whether treatment works in general.", "directness": "direct", "limitations": "Only one patient is described; no control group or long-term outcome data after surgery is given.", "followUp": "", "plainFinding": "Rare bowel pouch caused bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40627878/", "sourceText": "INTRODUCTION: The prevalence of Meckel's Diverticulum ranges from 0.3 % to 2.9 %. Although lower gastrointestinal bleeding is the most common presentation of Meckel's Diverticulum in children, it is a rare presentation in adults, as ectopic gastric mucosa (the source of bleeding) is less prevalent in this age group. CASE PRESENTATION: A 30-year-old male presented with painless per rectal bleeding for 2 weeks. No obvious positive finding was found on clinical examination. Routine baseline blood investigations, endoscopy, colonoscopy, and abdominal ultrasonography were normal. He had been experiencing similar episodes intermittently over the past three years, but the cause was not diagnosed earlier. Contrast Enhanced Computed Tomography (CECT) of the abdomen and pelvis confirmed the diagnosis of Meckel's Diverticulum, for which wedge resection was done. DISCUSSION: Hydrochloric acid produced by the ectopic gastric mucosa can erode the adjacent ileal mucosa, leading to ulceration and bleeding. The risk of developing complications in untreated asymptomatic Meckel's is 5 % - 6 %, whereas the incidence of complication following prophylactic resection is 1 %. Considering the risk-benefit ratio, some literature recommends prophylactic resection in all asymptomatic cases, whereas others suggest it only when one or more of the following risk factors are present: age < 50 years, diverticulum length > 2 cm, male gender, or presence of fibrous band. CONCLUSION: Meckel's Diverticulum can be thought of as one of the differentials in patients with painless rectal bleeding. Patient should be investigated for Meckel's if no other pathology is identified. Early diagnosis and treatment decrease the morbidity and mortality.", "provenance": [ { "field": "population", "quote": "A 30-year-old male presented with painless per rectal bleeding for 2 weeks." }, { "field": "intervention", "quote": "for which wedge resection was done" }, { "field": "comparator", "quote": "CASE PRESENTATION" }, { "field": "primaryOutcome", "quote": "Contrast Enhanced Computed Tomography (CECT) of the abdomen and pelvis confirmed the diagnosis of Meckel's Diverticulum" }, { "field": "result", "quote": "Contrast Enhanced Computed Tomography (CECT) of the abdomen and pelvis confirmed the diagnosis of Meckel's Diverticulum, for which wedge resection was done." }, { "field": "n", "quote": "A 30-year-old male presented with painless per rectal bleeding for 2 weeks." } ] }, { "id": "pmid:40525030", "pmid": "40525030", "doi": "10.7759/cureus.84214", "nctId": null, "pmcid": "PMC12168848", "title": "Cavernous Hemangioma of the Anal Canal Mimicking a Neoplasm: A Rare Cause of Lower Gastrointestinal Bleeding Successfully Treated With Transanal Excision", "firstAuthor": "Merchan", "multipleAuthors": true, "journal": "Cureus", "year": 2025, "design": "case-series", "n": 1, "nField": "reported", "population": "a 75-year-old woman with a year of painless rectal bleeding", "intervention": "surgical removal of the lesion through the anus", "comparator": "none", "primaryOutcome": "resolution of bleeding and recurrence of the lesion", "result": "symptoms completely resolved with no recurrence after three months", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common this cause is or how reliable the treatment is in general", "directness": "direct", "limitations": "only one patient was described, with a short three-month follow-up", "followUp": "three-month follow-up", "plainFinding": "Rare blood vessel growth, cured by surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40525030/", "sourceText": "Cavernous hemangiomas of the anal canal are exceptionally rare vascular malformations that may present with chronic rectal bleeding and are often misdiagnosed as hemorrhoids or neoplastic lesions. We report the case of a 75-year-old female patient with a one-year history of painless rectal bleeding and a soft polypoid lesion located 2 cm from the anal verge, within the anterior wall of the anal canal. Magnetic resonance imaging (MRI) revealed a hyperintense pseudonodular lesion consistent with a vascular malformation. Histopathological examination after biopsy confirmed the diagnosis of cavernous hemangioma. Definitive treatment was achieved through transanal full-thickness excision, with complete resolution of symptoms and no recurrence at the three-month follow-up. This case highlights the importance of including vascular lesions in the differential diagnosis of anorectal bleeding and illustrates the utility of MRI and organ-preserving surgery in the management of anal canal hemangiomas.", "provenance": [ { "field": "population", "quote": "a 75-year-old female patient with a one-year history of painless rectal bleeding" }, { "field": "intervention", "quote": "Definitive treatment was achieved through transanal full-thickness excision" }, { "field": "comparator", "quote": "Definitive treatment was achieved through transanal full-thickness excision, with complete resolution of symptoms and no recurrence at the three-month follow-up." }, { "field": "primaryOutcome", "quote": "complete resolution of symptoms and no recurrence at the three-month follow-up" }, { "field": "result", "quote": "complete resolution of symptoms and no recurrence at the three-month follow-up" }, { "field": "n", "quote": "a 75-year-old female patient" }, { "field": "followUp", "quote": "three-month follow-up" } ] }, { "id": "pmid:40506688", "pmid": "40506688", "doi": "10.1111/hdi.13273", "nctId": null, "pmcid": null, "title": "Acute Hemorrhagic Rectal Ulcer in a Uremic Patient: A Case Report and Literature Review", "firstAuthor": "Liu", "multipleAuthors": true, "journal": "Hemodial Int", "year": 2025, "design": "case-series", "n": 1, "nField": "reported", "population": "an elderly woman on dialysis for kidney failure", "intervention": "endoscopic treatment of a rectal ulcer (clips, injection, tissue glue)", "comparator": "none", "primaryOutcome": "stopping the rectal bleeding and survival", "result": "bleeding recurred despite treatment and she died after developing heart failure and multi-organ failure", "resultDirection": "harm", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show what usually happens or what helps.", "directness": "indirect", "limitations": "single case, patient had kidney failure and multiple other illnesses, no comparison group", "followUp": "", "plainFinding": "", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40506688/", "sourceText": "BACKGROUND: Acute hemorrhagic rectal ulcer (AHU) is a rare but severe cause of painless lower GI bleeding, mainly in elderly patients with comorbidities. Uremia increases bleeding risk due to platelet dysfunction and hemodialysis anticoagulation, but AHU in dialysis patients is underreported. AIMS: To report a case of AHU in a uremic hemodialysis patient and analyze management challenges. MATERIALS AND METHODS: A 78-year-old female with ESRD presented with rectal bleeding. Colonoscopy showed a 3 × 4 cm ulcer, managed with clips, injections, and adhesives. RESULTS: The patient experienced recurrent bleeding, requiring multiple endoscopic interventions (titanium clip placement, methylene blue-polydocanol injection, tissue adhesive). Despite initial hemostasis, she developed worsening heart failure and multi-organ failure, dying at home after ICU admission. DISCUSSION: Uremia, anticoagulation, and comorbidities fueled bleeding. Endoscopic therapy was key, but systemic decline dominated. Multidisciplinary care is vital for high-risk patients. CONCLUSION: This case instills awareness of the exigency regarding continuous observation and tailored management in this population of patients with high risk.", "provenance": [ { "field": "n", "quote": "A 78-year-old female with ESRD presented with rectal bleeding." }, { "field": "population", "quote": "A 78-year-old female with ESRD presented with rectal bleeding." }, { "field": "intervention", "quote": "managed with clips, injections, and adhesives" }, { "field": "comparator", "quote": "Endoscopic therapy was key, but systemic decline dominated." }, { "field": "primaryOutcome", "quote": "The patient experienced recurrent bleeding, requiring multiple endoscopic interventions" }, { "field": "result", "quote": "Despite initial hemostasis, she developed worsening heart failure and multi-organ failure, dying at home after ICU admission." } ] }, { "id": "pmid:40388936", "pmid": "40388936", "doi": "10.1177/00368504251344186", "nctId": null, "pmcid": "PMC12089723", "title": "Rectal arterial embolization for hemostasis of acute hemorrhagic rectal ulcers: A case series", "firstAuthor": "Gu", "multipleAuthors": true, "journal": "Sci Prog", "year": 2025, "design": "case-series", "n": 6, "nField": "reported", "population": "patients with massive painless rectal bleeding from acute hemorrhagic rectal ulcers", "intervention": "rectal arterial embolization to stop the bleeding", "comparator": "none (single-group case series, endoscopic treatment mentioned only as general alternative)", "primaryOutcome": "successful stopping of bleeding (technical and clinical success) and rebleeding", "result": "Treatment stopped bleeding in all patients initially, with technical success in 5 of 6 and rebleeding in 2 of 6", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a very small case series of only six patients with no comparison group, so it cannot reliably prove the treatment works better than alternatives.", "directness": "direct", "limitations": "Small number of patients (6), single center, no control group, and authors state further validation in larger cohorts is needed.", "followUp": "", "plainFinding": "Embolization stopped the rectal bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40388936/", "sourceText": "Acute hemorrhagic rectal ulcer (AHRU), though a relatively rare etiology of lower gastrointestinal bleeding, represents a critical clinical emergency characterized by sudden onset, painless, massive, and fresh rectal bleeding. While endoscopic hemostasis remains prominent therapy, its efficacy is limited in emergency settings by poor bowel preparation and obscured visualization. Rectal arterial embolization (RAE) offers a viable alternative, however, detailed descriptions of its application for AHRU in literature are lacking. Thus, we report a single-center experience of RAE in six patients with massive AHRU-related bleeding. Technical success was achieved in 83% (5/6) of cases, with clinical success was achieved in 100% cases (6/6). Rebleeding after initial RAE procedure occurred in 33% (2/6) of cases, one of which ultimately achieving hemostasis through transanal suturing after initial embolization failure. No major embolism-related complications were observed during follow-up. Moreover, complete embolization of rectal supplies demonstrated potential to reduce rebleeding risk, and empiric embolization may hold promise for managing refractory AHRU hemorrhage. These findings advocate for RAE as an effective alternative for AHRU hemorrhage, though further validation in larger cohorts is essential.", "provenance": [ { "field": "population", "quote": "sudden onset, painless, massive, and fresh rectal bleeding" }, { "field": "intervention", "quote": "Rectal arterial embolization (RAE)" }, { "field": "comparator", "quote": "endoscopic hemostasis remains prominent therapy" }, { "field": "primaryOutcome", "quote": "Technical success was achieved in 83% (5/6) of cases, with clinical success was achieved in 100% cases (6/6)" }, { "field": "result", "quote": "Technical success was achieved in 83% (5/6) of cases, with clinical success was achieved in 100% cases (6/6). Rebleeding after initial RAE procedure occurred in 33% (2/6) of cases" }, { "field": "n", "quote": "six patients with massive AHRU-related bleeding" } ] }, { "id": "pmid:39220052", "pmid": "39220052", "doi": "10.4240/wjgs.v16.i8.2735", "nctId": null, "pmcid": "PMC11362948", "title": "Anorectal hemangioma, a rare cause of lower gastrointestinal bleeding, treated with selective embolization: A case report", "firstAuthor": "Pospisilova", "multipleAuthors": true, "journal": "World J Gastrointest Surg", "year": 2024, "design": "case-series", "n": 1, "nField": "reported", "population": "21-year-old man with painless rectal bleeding since childhood, initially misdiagnosed as ulcerative colitis", "intervention": "selective embolization (blocking blood vessels) of an anorectal hemangioma", "comparator": "surgical treatment (which carried high risk of fecal incontinence)", "primaryOutcome": "improvement in rectal bleeding and healing of the lesion", "result": "Bleeding improved temporarily after embolization; a small ischemic ulcer developed but healed without narrowing of the bowel", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how well this treatment works in general.", "directness": "direct", "limitations": "Only one patient was described, and the abstract notes the improvement was 'temporarily,' with no long-term follow-up data given.", "followUp": "", "plainFinding": "Rare blood vessel growth, treated with embolization.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39220052/", "sourceText": "BACKGROUND: Anorectal hemangioma is a rare and frequently misdiagnosed cause of lower gastrointestinal (GI) bleeding. Here, we present a minimally invasive therapy with selective embolization. CASE SUMMARY: A 21-year-old male patient experienced painless rectal bleeding since childhood and was treated for ulcerative colitis. Diagnostic studies later revealed specific characteristics for vascular lesions-anorectal hemangiomas. The severity of rectal bleeding caused symptomatic anemia and possible surgical treatment was associated with a high risk of fecal incontinence. Here, we present selective embolization, a minimally invasive therapeutic approach that is proven as an alternative therapeutic method of choice. The patient significantly improved temporarily and had a small ischemic ulcer, which healed with a control colonoscopy and developed no stenosis. CONCLUSION: Awareness of the clinical and radiological features of GI hemangiomas may help improve diagnostics and avoid inappropriate therapeutic procedures.", "provenance": [ { "field": "population", "quote": "A 21-year-old male patient experienced painless rectal bleeding since childhood and was treated for ulcerative colitis." }, { "field": "intervention", "quote": "selective embolization, a minimally invasive therapeutic approach that is proven as an alternative therapeutic method of choice" }, { "field": "comparator", "quote": "possible surgical treatment was associated with a high risk of fecal incontinence" }, { "field": "primaryOutcome", "quote": "The patient significantly improved temporarily and had a small ischemic ulcer, which healed with a control colonoscopy and developed no stenosis." }, { "field": "result", "quote": "The patient significantly improved temporarily and had a small ischemic ulcer, which healed with a control colonoscopy and developed no stenosis." }, { "field": "n", "quote": "A 21-year-old male patient" } ] }, { "id": "pmid:38646340", "pmid": "38646340", "doi": "10.7759/cureus.56678", "nctId": null, "pmcid": "PMC11032499", "title": "Colonic Angiolipoma: A Rare Cause of Chronic Anemia and Rectal Bleeding", "firstAuthor": "Alharbi", "multipleAuthors": true, "journal": "Cureus", "year": 2024, "design": "case-series", "n": 1, "nField": "reported", "population": "52-year-old woman with no major health problems, painless rectal bleeding and anemia for six months", "intervention": "surgical removal of a colon tumor (angiolipoma)", "comparator": "none", "primaryOutcome": "resolution of bleeding and anemia", "result": "after surgery, symptoms went away and blood counts returned to normal", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show what usually causes or cures this problem.", "directness": "direct", "limitations": "Only one patient was described, so findings may not apply to others.", "followUp": "", "plainFinding": "Rare tumor removed, bleeding resolved.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38646340/", "sourceText": "Angiolipomas are rare, benign tumors characterized by a mixture of adipose tissue and blood vessels, distinguishing them from lipomas. This case involves a 52-year-old woman with no significant medical history who presented with generalized weakness, fatigue, and intermittent, painless rectal bleeding over six months, initially dismissed as hemorrhoidal. Despite exhibiting mild pallor and trace rectal bleeding upon examination, significant iron-deficiency anemia was diagnosed through laboratory tests. Incorporating colonoscopy and computed tomography, the diagnostic process identified a 2 cm submucosal lesion in the ascending colon, characterized as a well-defined, fat-density mass. Histopathological analysis following surgical resection confirmed the diagnosis of a colonic angiolipoma. The patient's recovery, marked by the resolution of symptoms and normalization of hemoglobin levels, underscores the effectiveness of surgical treatment. This case highlights the diagnostic challenges posed by colonic angiolipomas due to their nonspecific symptoms. It emphasizes the importance of considering such rare entities in the differential diagnosis of gastrointestinal symptoms. This approach facilitates prompt and appropriate treatment, enriching the limited literature and advocating for clinical vigilance and interdisciplinary diagnostic strategies.", "provenance": [ { "field": "population", "quote": "a 52-year-old woman with no significant medical history who presented with generalized weakness, fatigue, and intermittent, painless rectal bleeding over six months" }, { "field": "n", "quote": "a 52-year-old woman" }, { "field": "intervention", "quote": "Histopathological analysis following surgical resection confirmed the diagnosis of a colonic angiolipoma" }, { "field": "comparator", "quote": "The patient's recovery, marked by the resolution of symptoms and normalization of hemoglobin levels, underscores the effectiveness of surgical treatment." }, { "field": "primaryOutcome", "quote": "The patient's recovery, marked by the resolution of symptoms and normalization of hemoglobin levels" }, { "field": "result", "quote": "The patient's recovery, marked by the resolution of symptoms and normalization of hemoglobin levels, underscores the effectiveness of surgical treatment." } ] }, { "id": "pmid:38274300", "pmid": "38274300", "doi": "10.14309/crj.0000000000001250", "nctId": null, "pmcid": "PMC10810580", "title": "An Unusual Case of Gastric Heterotopia Presenting as Rectal Prolapse", "firstAuthor": "D'Sa", "multipleAuthors": true, "journal": "ACG Case Rep J", "year": 2024, "design": "case-series", "n": 1, "nField": "reported", "population": "a 2-year-old previously healthy girl with rectal prolapse and painless bleeding", "intervention": "endoscopic removal of misplaced stomach-like tissue in the rectum (after acid-reducing medication didn't work)", "comparator": "none", "primaryOutcome": "complete removal of the abnormal tissue causing bleeding", "result": "the abnormal tissue was completely removed by endoscopic surgery", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how common or reliable this cause or treatment is.", "directness": "direct", "limitations": "Only one patient was described, and the abstract does not report how she did after the procedure.", "followUp": "", "plainFinding": "Rare: stomach-tissue growth in rectum.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38274300/", "sourceText": "Heterotopic gastric mucosa (HGM) involving the rectum is an uncommon finding. It is especially rare in young children. Rectal prolapse is an uncommon presentation of HGM. We report a case of HGM in the rectum of a 2-year-old previously healthy girl, who presented with rectal prolapse and painless bleeding. Endoscopic mucosal resection was performed to completely resect the lesion after the patient failed to respond to proton pump inhibitors. This case underscores the importance of considering HGM involving the rectum as a cause of rectal prolapse in young pediatric patients.", "provenance": [ { "field": "n", "quote": "We report a case of HGM in the rectum of a 2-year-old previously healthy girl" }, { "field": "population", "quote": "a 2-year-old previously healthy girl, who presented with rectal prolapse and painless bleeding" }, { "field": "intervention", "quote": "Endoscopic mucosal resection was performed to completely resect the lesion after the patient failed to respond to proton pump inhibitors." }, { "field": "comparator", "quote": "after the patient failed to respond to proton pump inhibitors" }, { "field": "primaryOutcome", "quote": "Endoscopic mucosal resection was performed to completely resect the lesion" }, { "field": "result", "quote": "Endoscopic mucosal resection was performed to completely resect the lesion after the patient failed to respond to proton pump inhibitors." } ] }, { "id": "pmid:41341644", "pmid": "41341644", "doi": "10.52787/agl.v53i3.296", "nctId": null, "pmcid": "PMC12668457", "title": "[Videocapsule Endoscopy as a Diagnostic Tool for Meckel's Diverticulum in Pediatrics: a Case Report]", "firstAuthor": "Acevedo Forero", "multipleAuthors": true, "journal": "Acta Gastroenterol Latinoam", "year": 2023, "design": "case-series", "n": null, "nField": "not-reported", "population": "children with suspected Meckel's diverticulum causing rectal bleeding", "intervention": "video capsule endoscopy to directly view the small intestine", "comparator": "no comparator; Meckel's scan mentioned as alternative diagnostic test", "primaryOutcome": "accurate diagnosis of the cause of painless rectal bleeding", "result": "video capsule endoscopy allowed direct visualization to clarify the cause of small intestine bleeding", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single case report, so it cannot show how often this diagnosis explains painless bleeding in general.", "directness": "direct", "limitations": "Case report format with no patient numbers given; findings may not generalize.", "followUp": "", "plainFinding": "Painless bleeding found to be Meckel's diverticulum.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41341644/", "sourceText": "Meckel's diverticulum is a common congenital anomaly of the small intestine caused by incomplete obliteration of the omphalomesenteric duct. Most patients are asymptomatic, and the diagnosis is usually made incidentally on imaging studies. The most common symptom is painless rectal bleeding; however, the presentation can be varied. There are different diagnostic tools for symptomatic, among which the most sensitive is Meckel's scan. However, direct visualization is the way to make an accurate diagnosis, which can be done through video capsule endoscopy, a useful tool to clarify the etiology of bleeding in the small intestine.", "provenance": [ { "field": "population", "quote": "Meckel's diverticulum is a common congenital anomaly of the small intestine" }, { "field": "intervention", "quote": "video capsule endoscopy, a useful tool to clarify the etiology of bleeding in the small intestine" }, { "field": "comparator", "quote": "the most sensitive is Meckel's scan" }, { "field": "primaryOutcome", "quote": "direct visualization is the way to make an accurate diagnosis" }, { "field": "result", "quote": "video capsule endoscopy, a useful tool to clarify the etiology of bleeding in the small intestine" }, { "field": "population", "quote": "The most common symptom is painless rectal bleeding" } ] }, { "id": "pmid:37464856", "pmid": "37464856", "doi": "10.31729/jnma.8177", "nctId": null, "pmcid": "PMC10276938", "title": "Cap Polyposis: A Case Report", "firstAuthor": "Khadka", "multipleAuthors": true, "journal": "JNMA J Nepal Med Assoc", "year": 2023, "design": "case-series", "n": 1, "nField": "reported", "population": "18-year-old male with one year of painless rectal bleeding", "intervention": "polypectomy (removal of polyps) in multiple settings", "comparator": "none reported", "primaryOutcome": "resolution of polyposis and bleeding after treatment", "result": "patient treated with immediate and interval polypectomy for cap polyposis, described as curable", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single case report, which cannot show whether the treatment works in general.", "directness": "direct", "limitations": "Only one patient was described, with no comparison group and no long-term outcome data reported.", "followUp": "", "plainFinding": "Polyp removal treated painless rectal bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37464856/", "sourceText": "UNLABELLED: Cap polyposis is a gastrointestinal disease with multiple inflammatory polyps between the distal colon and rectum. Its symptoms overlap with inflammatory bowel disease with typical endoscopic features of multiple sessile polyps in the rectum and sigmoid colon, located at the apices of transverse folds. Microscopically, the polyps consist of elongated, tortuous, and distended crypts covered by a \"cap\" of inflammatory granulation tissue. In this report, we present a case of a 18-year-old male patient who underwent polypectomy for polyposis in multiple settings. He presented with one year of painless rectal bleeding and polyposis in a recto-sigmoid area on colonoscopy, with a single polyp in the sigmoid area and multiple polyps in the rectum. He was managed with immediate and interval polypectomy. Though cap polyposis is rare, it can be cured as it is laparoscopically resectable. KEYWORDS: case reports; granulation tissue; inflammatory bowel diseases; polyps.", "provenance": [ { "field": "n", "quote": "a case of a 18-year-old male patient" }, { "field": "population", "quote": "He presented with one year of painless rectal bleeding and polyposis in a recto-sigmoid area on colonoscopy" }, { "field": "intervention", "quote": "He was managed with immediate and interval polypectomy." }, { "field": "comparator", "quote": "underwent polypectomy for polyposis in multiple settings" }, { "field": "primaryOutcome", "quote": "Though cap polyposis is rare, it can be cured as it is laparoscopically resectable." }, { "field": "result", "quote": "He was managed with immediate and interval polypectomy." } ] }, { "id": "pmid:37425531", "pmid": "37425531", "doi": "10.7759/cureus.40050", "nctId": null, "pmcid": "PMC10324985", "title": "Dieulafoy's Lesion of the Duodenum: A Rare and Fatal Cause of Gastrointestinal Bleed", "firstAuthor": "Qasim", "multipleAuthors": true, "journal": "Cureus", "year": 2023, "design": "case-series", "n": 1, "nField": "reported", "population": "a 71-year-old woman with severe iron deficiency anemia needing repeated blood transfusions", "intervention": "endoscopic diagnosis and treatment of a bleeding vessel in the duodenum (Dieulafoy's lesion)", "comparator": "none", "primaryOutcome": "identifying the cause of gastrointestinal bleeding", "result": "found to have a duodenal Dieulafoy lesion, a rare cause of painless GI bleeding", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common this cause is or how well treatment works in general.", "directness": "direct", "limitations": "only one patient described; no comparison group or outcome data after treatment reported.", "followUp": "", "plainFinding": "Rare vessel defect found causing bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37425531/", "sourceText": "Dieulafoy's lesion (DL) is an unusual cause of recurrent gastrointestinal bleeding that can be fatal. It can occur in various parts of the gastrointestinal (GI) tract, most commonly located in the stomach, especially at the level of lesser curvature; however, it can occur in other parts, including the colon, esophagus, and duodenum. A duodenal Dieulafoy lesion is characterized by the presence of a larger-caliber artery that protrudes through the GI mucosa and can lead to massive hemorrhage. The exact cause of DL is yet to be determined. Clinical presentation includes painless upper GI bleeding, including melena, hematochezia, and hematemesis, or rarely iron deficiency anemia (IDA); however, most of the patients are asymptomatic. Some patients also have non-gastrointestinal comorbidities such as hypertension, diabetes, and chronic kidney disease (CKD). The diagnosis is established by esophagogastroduodenoscopy (EGD), which includes the presence of micro pulsatile streaming from a mucosal defect, the appearance of a fresh, densely adherent clot with a narrow point of attachment to a minute mucosal defect, and the visualization of a protruding vessel with or without bleeding. Initial EGD can be non-diagnostic due to the relatively small size of the lesion. Other diagnostic modalities include endoscopic ultrasound and mesenteric angiography. The treatment of duodenal DL includes thermal electrocoagulation, local epinephrine injection, sclerotherapy, banding, and hemoclipping. We present here a case of a 71-year-old female who had a history of severe IDA requiring multiple blood transfusions and intravenous iron in the past and was found to have duodenal DL.", "provenance": [ { "field": "n", "quote": "a 71-year-old female" }, { "field": "population", "quote": "a 71-year-old female who had a history of severe IDA requiring multiple blood transfusions and intravenous iron in the past" }, { "field": "intervention", "quote": "The diagnosis is established by esophagogastroduodenoscopy (EGD)" }, { "field": "comparator", "quote": "We present here a case of a 71-year-old female" }, { "field": "primaryOutcome", "quote": "was found to have duodenal DL" }, { "field": "result", "quote": "was found to have duodenal DL" } ] }, { "id": "pmid:37106517", "pmid": "37106517", "doi": "10.2174/1871526523666230427115436", "nctId": null, "pmcid": null, "title": "Hemorrhoid Disease: A Review on Treatment, Clinical Research and Patent Data", "firstAuthor": "Devi", "multipleAuthors": true, "journal": "Infect Disord Drug Targets", "year": 2023, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoid disease", "intervention": "various treatments for hemorrhoids (reviewed)", "comparator": "", "primaryOutcome": "safety and clinical efficacy of hemorrhoid treatments", "result": "review summarizes newer molecules and past studies but does not report a specific outcome result", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a narrative review of literature and patents, not a study testing a treatment, so it gives no direct evidence about outcomes.", "directness": "indirect", "limitations": "no original data, no outcome statistics reported, purpose is to summarize drug development and patents rather than test treatment effectiveness", "followUp": "", "plainFinding": "No specific finding reported here.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/37106517/", "sourceText": "BACKGROUND: Hemorrhoid disease (HD) is an anal-rectal ailment that is commonly painful or may be painless and causes rectal bleeding with or without prolapsing anal tissue. It is generally associated with bleeding, prolapse, pruritus, and discomfort, which results in a diminished quality of life and well-being. OBJECTIVE: To highlight the recent developments in terms of safety, clinical efficacy, and marketed formulation for the effective management of hemorrhoids. METHOD: Reported literature available on Scopus, PubMed, Science Direct, Clinicaltrails.gov, and from many reputed foundations has been studied to summarize the recent development and clinical studies for the management of hemorrhoids. RESULTS AND CONCLUSION: The high incidence of hemorrhoids obliges the development of new molecules; therefore, safe and efficient drugs to confer protection against hemorrhoids are urgently needed. This review article mainly focuses on the newer molecules to overcome hemorrhoids and also emphasizes various studies carried out in the past.", "provenance": [ { "field": "population", "quote": "Hemorrhoid disease (HD) is an anal-rectal ailment that is commonly painful or may be painless and causes rectal bleeding with or without prolapsing anal tissue." }, { "field": "intervention", "quote": "newer molecules to overcome hemorrhoids" }, { "field": "primaryOutcome", "quote": "To highlight the recent developments in terms of safety, clinical efficacy, and marketed formulation for the effective management of hemorrhoids." }, { "field": "result", "quote": "This review article mainly focuses on the newer molecules to overcome hemorrhoids and also emphasizes various studies carried out in the past." } ] }, { "id": "pmid:38477093", "pmid": "38477093", "doi": "10.5114/pjp.2023.133846", "nctId": null, "pmcid": null, "title": "Primary amelanotic melanoma of anorectum - a rare case report with diagnostic challenge", "firstAuthor": "Singh", "multipleAuthors": true, "journal": "Pol J Pathol", "year": 2023, "design": "case-series", "n": 1, "nField": "reported", "population": "a 47-year-old woman with painless rectal bleeding", "intervention": "biopsy with histomorphology and immunohistochemistry to diagnose the cause", "comparator": "", "primaryOutcome": "identifying the cause of painless rectal bleeding", "result": "diagnosed as a rare amelanotic malignant melanoma of the anorectum, treated with surgery", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common this cause is or how well treatments work generally", "directness": "direct", "limitations": "only one patient; no comparison group; cannot generalize cause of rectal bleeding to other patients", "followUp": "", "plainFinding": "Rare melanoma cause found.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38477093/", "sourceText": "Anorectal melanoma is an exceptionally rare and aggressive form of cancer. One per cent of anorectal malignant tumours are anorectal malignant melanomas, which are exceedingly uncommon. We report a case of a 47-year-old woman who experienced painless rectal bleeding. On examination, an irregular lump was seen in the posterior rectal wall, measuring 4 × 3.7 cm. Biopsies were obtained under endoscopic guidance for histomorphology and immunohistochemistry. The biopsy examination showed nests of tumour mass in the lamina and muscularis mucosae. The tumour mass was composed of round to oval cells having enlarged nuclei, conspicuous nucleoli, and a scant amount of cytoplasm. No melanin pigmentation was noted in the tumour cells. HMB-45, S-100, and vimentin were all detected by immunohistochemistry. A definitive diagnosis of amelanotic malignant melanoma was rendered. The patient underwent abdominoperineal resection with a hysterectomy and bilateral salpingo-oophorectomy. Anorectal melanoma presents with bleeding per rectum and is often misdiagnosed as internal haemorrhoids or adenocarcinoma clinically. Amelanotic melanoma, which lacks melanin pigment, is difficult to diagnose. Patients who appear with rectal bleeding should have a malignant melanoma evaluation as a possible differential diagnosis, and suitable diagnostic procedures, such as a colonoscopy and a biopsy with immunohistochemistry, should be carried out to arrive at a conclusive diagnosis.", "provenance": [ { "field": "n", "quote": "We report a case of a 47-year-old woman who experienced painless rectal bleeding." }, { "field": "population", "quote": "We report a case of a 47-year-old woman who experienced painless rectal bleeding." }, { "field": "intervention", "quote": "Biopsies were obtained under endoscopic guidance for histomorphology and immunohistochemistry." }, { "field": "primaryOutcome", "quote": "A definitive diagnosis of amelanotic malignant melanoma was rendered." }, { "field": "result", "quote": "The patient underwent abdominoperineal resection with a hysterectomy and bilateral salpingo-oophorectomy." } ] }, { "id": "pmid:36304634", "pmid": "36304634", "doi": "10.1080/08998280.2022.2101559", "nctId": null, "pmcid": "PMC9586572", "title": "A giant hemangioma of the sigmoid colon as a cause of lower gastrointestinal bleeding in a young man", "firstAuthor": "Fair", "multipleAuthors": true, "journal": "Proc (Bayl Univ Med Cent)", "year": 2022, "design": "case-series", "n": 1, "nField": "reported", "population": "37-year-old man with recurrent painless rectal bleeding for 2 months", "intervention": "laparoscopic surgical removal of the sigmoid colon section", "comparator": "none", "primaryOutcome": "successful treatment of the bleeding source", "result": "surgery successfully removed the large hemangioma causing bleeding", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how common this cause is or how well treatment works in general.", "directness": "direct", "limitations": "Single case report; no comparison group; findings may not generalize to other patients.", "followUp": "", "plainFinding": "Rare colon growth found and removed.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36304634/", "sourceText": "Although hemangiomas are among the rarest causes of lower gastrointestinal bleeding, they should be considered in young adults with recurrent, painless gastrointestinal bleeding. We present a case report of a 37-year-old man with a 2-month history of intermittent rectal bleeding who had a single large hemangioma in the sigmoid colon, successfully treated with elective laparoscopic sigmoid resection.", "provenance": [ { "field": "n", "quote": "a 37-year-old man" }, { "field": "population", "quote": "a 37-year-old man with a 2-month history of intermittent rectal bleeding" }, { "field": "intervention", "quote": "successfully treated with elective laparoscopic sigmoid resection" }, { "field": "comparator", "quote": "successfully treated with elective laparoscopic sigmoid resection" }, { "field": "primaryOutcome", "quote": "successfully treated with elective laparoscopic sigmoid resection" }, { "field": "result", "quote": "successfully treated with elective laparoscopic sigmoid resection" } ] }, { "id": "pmid:36211606", "pmid": "36211606", "doi": "10.1259/bjrcr.20220084", "nctId": null, "pmcid": "PMC9518733", "title": "A rectosigmoid haemangioma: A rare etiology of rectal bleeding", "firstAuthor": "Abdulghaffar", "multipleAuthors": true, "journal": "BJR Case Rep", "year": 2022, "design": "case-series", "n": 1, "nField": "reported", "population": "26-year-old man with long history of recurrent rectal bleeding", "intervention": "CT scan, MRI imaging and surgical resection of the rectosigmoid colon with colo-anal anastomosis", "comparator": "none", "primaryOutcome": "diagnosis and treatment of the cause of rectal bleeding", "result": "CT and MRI confirmed a cavernous hemangioma of the rectosigmoid colon, treated with surgical resection", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how common this cause is or how well treatment works in general.", "directness": "direct", "limitations": "Only one patient was described, with no comparison group or long-term outcome data reported.", "followUp": "", "plainFinding": "Rare blood vessel growth caused bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36211606/", "sourceText": "Cavernous haemangiomas of the rectosigmoid colon are rare benign vascular neoplasms of the GI tract. Patients usually present at a younger age with various degree of rectal bleeding ranging from mild painless episodic bleeding to life-threatening hemorrhage. High index of suspicion and early diagnosis is crucial to avoid unnecessary biopsy and inappropriate management. We report a case of a 26-year-old male patient with a long history of recurrent rectal bleeding. Contrast-enhanced CT scan of the abdomen and pelvis and MRI confirmed the diagnosis of cavernous hemangioma. Further surgical treatment with rectosigmoid resection and colo-anal anastomosis represents the optimum path of management for our patient.", "provenance": [ { "field": "n", "quote": "a 26-year-old male patient with a long history of recurrent rectal bleeding" }, { "field": "population", "quote": "a 26-year-old male patient with a long history of recurrent rectal bleeding" }, { "field": "intervention", "quote": "Contrast-enhanced CT scan of the abdomen and pelvis and MRI confirmed the diagnosis of cavernous hemangioma. Further surgical treatment with rectosigmoid resection and colo-anal anastomosis represents the optimum path of management for our patient." }, { "field": "comparator", "quote": "Further surgical treatment with rectosigmoid resection and colo-anal anastomosis represents the optimum path of management for our patient." }, { "field": "result", "quote": "Contrast-enhanced CT scan of the abdomen and pelvis and MRI confirmed the diagnosis of cavernous hemangioma." }, { "field": "primaryOutcome", "quote": "Contrast-enhanced CT scan of the abdomen and pelvis and MRI confirmed the diagnosis of cavernous hemangioma." } ] }, { "id": "pmid:36074650", "pmid": "36074650", "doi": "10.1111/ans.18023", "nctId": null, "pmcid": null, "title": "Adjunctive endoscopic clip marking enhances non-operative management of massive lower gastrointestinal bleeding", "firstAuthor": "Hui", "multipleAuthors": true, "journal": "ANZ J Surg", "year": 2022, "design": "case-series", "n": 36, "nField": "reported", "population": "patients with massive lower gastrointestinal bleeding from colon diverticular disease, often causing painless rectal bleeding", "intervention": "endoscopic clip marking (EPM) to guide artery-blocking embolization (TAE) of the bleeding vessel", "comparator": "no separate comparison group; outcomes reported within the same treated patients", "primaryOutcome": "whether bleeding could be controlled without surgery (successful non-operative management) and survival", "result": "non-operative management succeeded in 83.3% of patients, with 0% death within 30 days", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a small, single-centre case series without a comparison group, so it can't prove the technique is better than usual care.", "directness": "indirect", "limitations": "Retrospective case series spanning many years, small number of patients, no control group for comparison, and only six patients had the specific clip-then-embolization sequence analysed in detail.", "followUp": "", "plainFinding": "Clip-guided embolization controlled bleeding well.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36074650/", "sourceText": "BACKGROUNDS: Massive lower gastrointestinal bleeding (LGB) is common especially in elderly patients. Controversy in the approach to management stems from location of bleeding and morbidity of surgery. Colonic diverticula disease (CD) is the leading cause of painless haematochezia and haemodynamic instability. METHODS: The use of a novel technique of endoscopic pre-marking (EPM) with radiopaque metal clips to localize is described. EPM guided superselective active transarterial embolization (A-TAE) when active vascular blush was seen. When no active contrast extravasation was seen, EPM also guided prophylactic superselective transarterial embolization (P-TAE). RESULTS: From May 2004 to December 2021, there were 36 patients with massive LGB from diverticular disease encompassing 44 separate bleeding episodes. Spontaneous haemostasis was observed in 18.2% (8/44). The overall success rate in non-operative management was 83.3% (30/36) patients. Three patients proceeded for emergency surgery. Of the 36 patients, six patients had documented EPM followed by TAE due to recurrent bleed in the same episode. A-TAE was performed in two patients. P-TAE was performed in the four patients without active contrast extravasation. Initial haemostasis was successful in five out of six patients. One patient failed embolization and proceeded to emergency surgery. Three months later, one patient encountered late rebleeding and was scheduled for elective colectomy. None of the six developed intestinal infarction from embolization. The 30-day mortality was 0%. CONCLUSION: A consistent approach to LGB and defined protocol of endoscopic haemostasis, with routine EPM and embolization, has the potential to mitigate the morbidity and mortality in this group of vulnerable patients.", "provenance": [ { "field": "n", "quote": "there were 36 patients with massive LGB from diverticular disease encompassing 44 separate bleeding episodes" }, { "field": "population", "quote": "Colonic diverticula disease (CD) is the leading cause of painless haematochezia and haemodynamic instability." }, { "field": "intervention", "quote": "The use of a novel technique of endoscopic pre-marking (EPM) with radiopaque metal clips to localize is described. EPM guided superselective active transarterial embolization (A-TAE)" }, { "field": "comparator", "quote": "Spontaneous haemostasis was observed in 18.2% (8/44)." }, { "field": "primaryOutcome", "quote": "The overall success rate in non-operative management was 83.3% (30/36) patients." }, { "field": "result", "quote": "The overall success rate in non-operative management was 83.3% (30/36) patients." }, { "field": "result", "quote": "The 30-day mortality was 0%." } ] }, { "id": "pmid:35429226", "pmid": "35429226", "doi": "10.1111/ans.17676", "nctId": null, "pmcid": "PMC9324913", "title": "Changing the routine: a move to patient initiated follow up to improve surgical outpatient clinic", "firstAuthor": "Balhorn", "multipleAuthors": true, "journal": "ANZ J Surg", "year": 2022, "design": "retrospective", "n": 268, "nField": "reported", "population": "patients referred with rectal bleeding (painful and painless) at a hospital surgical clinic", "intervention": "new clinic protocol allowing patient-initiated follow up (PIFU)", "comparator": "historical controls using traditional physician-initiated follow up", "primaryOutcome": "rate of follow-up appointments needed", "result": "new clinic protocol had far fewer follow-up visits than old system, with similar detection of cancer", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a small retrospective comparison with historical (not randomized) controls, so differences could be due to other factors over time.", "directness": "indirect", "limitations": "Abstract does not discuss causes of rectal bleeding, uses historical rather than randomized controls, and does not report how diagnoses were made.", "followUp": "5 year follow up", "plainFinding": "Fewer follow-up visits needed overall.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35429226/", "sourceText": "INTRODUCTION: Patient initiated follow up (PIFU) allows patients to initiate a hospital follow up appointment on an 'as required' basis in contrast to the traditional physician-initiated model. We present a clinical pathway for patients referred with rectal bleeding at a large tertiary public hospital in South Auckland, New Zealand and demonstrate the utility of PIFU and its impact on reducing follow up appointments. METHOD: The purpose of the pathway was to allow standardized care by the clinicians and allow for PIFU. Two separate protocols were developed - 'Painful PR bleeding' and 'Painless PR bleeding'. A new clinic (NC) was started following these protocols, and this was compared to historical controls (HC). The primary outcome was the rate of follow up appointments. RESULTS: There were 133 patients in the NC and 135 in the HC, with significantly less follow ups in the NC (6% versus 45%, p < 0.0001). A small percentage of patients in the NC group were directly discharged (10%) whilst 70% of patients were discharged with a PIFU card. Thirty phone calls were made using PIFU, with 10 patients returning to clinic and 20 requiring advice and reassurance only. At 5 year follow up, there was a single colorectal malignancy found in both groups. CONCLUSION: Initiating a protocol that includes patient initiated follow up vastly reduces the need for routine return to clinic for the majority of patients, without sacrificing patient care. A protocolised approach to clinic for other areas in general surgery should be considered.", "provenance": [ { "field": "population", "quote": "patients referred with rectal bleeding at a large tertiary public hospital in South Auckland, New Zealand" }, { "field": "intervention", "quote": "Patient initiated follow up (PIFU) allows patients to initiate a hospital follow up appointment on an 'as required' basis" }, { "field": "comparator", "quote": "this was compared to historical controls (HC)" }, { "field": "primaryOutcome", "quote": "The primary outcome was the rate of follow up appointments." }, { "field": "result", "quote": "There were 133 patients in the NC and 135 in the HC, with significantly less follow ups in the NC (6% versus 45%, p < 0.0001)." }, { "field": "n", "quote": "There were 133 patients in the NC and 135 in the HC" }, { "field": "followUp", "quote": "At 5 year follow up, there was a single colorectal malignancy found in both groups." } ] }, { "id": "pmid:34851591", "pmid": "34851591", "doi": "10.24875/CIRU.20000746", "nctId": null, "pmcid": null, "title": "Diffuse cavernous hemangioma of the rectum", "firstAuthor": "Hermosa", "multipleAuthors": true, "journal": "Cir Cir", "year": 2021, "design": "case-series", "n": 1, "nField": "reported", "population": "34-year-old man with a vascular growth in the rectum and anus", "intervention": "surgical removal of the rectum and anus (abdominoperineal resection)", "comparator": "", "primaryOutcome": "diagnosis and treatment of painless rectal bleeding", "result": "the patient needed full removal surgery because the growth affected the anal sphincter area", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a report on a single patient, so it cannot show how common this cause is or how well treatment works in general.", "directness": "direct", "limitations": "Single case report; no comparison group; findings may not generalize.", "followUp": "", "plainFinding": "Rare vascular tumor causing painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34851591/", "sourceText": "Diffuse cavernous hemangioma (DCH) is a rare benign vascular lesion. The rectosigmoid colon is the most common site of this disease. It affects mainly young adults. The most frequent symptom is chronic rectal bleeding which is painless, often begins in the infancy and sometimes is uncontrollable. Endoscopy is the diagnose method of choice and complete surgical excision with sphincter-saving procedure is the primary mode of treatment. A high index of suspicion and a correct diagnose is necessary. We present a 34-year-old male with a DCH of the rectum and anus who required an APR because of affection of dentate line.", "provenance": [ { "field": "population", "quote": "We present a 34-year-old male with a DCH of the rectum and anus" }, { "field": "intervention", "quote": "required an APR because of affection of dentate line" }, { "field": "primaryOutcome", "quote": "The most frequent symptom is chronic rectal bleeding which is painless, often begins in the infancy and sometimes is uncontrollable." }, { "field": "result", "quote": "We present a 34-year-old male with a DCH of the rectum and anus who required an APR because of affection of dentate line." }, { "field": "n", "quote": "We present a 34-year-old male" } ] }, { "id": "pmid:34507344", "pmid": "34507344", "doi": "10.1097/PEC.0000000000002537", "nctId": null, "pmcid": null, "title": "Meckel's Masquerade: Penetrating the Disguise", "firstAuthor": "Callanan", "multipleAuthors": true, "journal": "Pediatr Emerg Care", "year": 2021, "design": "case-series", "n": 4, "nField": "reported", "population": "children seen in a pediatric emergency department with abdominal pain", "intervention": "none - observational case series", "comparator": "none", "primaryOutcome": "how Meckel's diverticulum complications presented in these patients", "result": "all 4 patients had abdominal pain from Meckel's diverticulum complications, none had painless rectal bleeding", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a tiny report of only 4 patients from one hospital describing cases, not a study comparing treatments or testing a cause directly.", "directness": "indirect", "limitations": "Very small case series (4 patients) from a single center over 6 months, describing abdominal pain presentations rather than painless bleeding specifically.", "followUp": "", "plainFinding": "Meckel's here caused pain, not painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34507344/", "sourceText": "Children with abdominal pain are frequently seen in emergency departments. Physicians and parents worry about appendicitis; physicians are also concerned about intussusception and bowel obstruction in patients with previous surgical procedures. Sometimes the patient is ill, and the diagnosis is elusive. In a 6-month period at our pediatric emergency department with an annual census of 57,400 patients, we cared for 4 patients who presented with abdominal pain due to complications of Meckel's diverticulum. None presented with painless rectal bleeding, the complication of which physicians are most aware. We are reporting these patients to raise awareness of Meckel's diverticulum as a cause of acute abdomen in children. Meckel's diverticulum may masquerade as appendicitis, an abdominal mass, intussusception, or a complication of severe constipation.", "provenance": [ { "field": "n", "quote": "we cared for 4 patients who presented with abdominal pain due to complications of Meckel's diverticulum" }, { "field": "population", "quote": "Children with abdominal pain are frequently seen in emergency departments" }, { "field": "intervention", "quote": "we cared for 4 patients who presented with abdominal pain due to complications of Meckel's diverticulum" }, { "field": "comparator", "quote": "we cared for 4 patients who presented with abdominal pain due to complications of Meckel's diverticulum" }, { "field": "primaryOutcome", "quote": "Meckel's diverticulum may masquerade as appendicitis, an abdominal mass, intussusception, or a complication of severe constipation" }, { "field": "result", "quote": "None presented with painless rectal bleeding, the complication of which physicians are most aware" } ] }, { "id": "pmid:34388140", "pmid": "34388140", "doi": "10.14309/ajg.0000000000001413", "nctId": null, "pmcid": "PMC8560163", "title": "Identifying Bleeding Etiologies by Endoscopy Affected Outcomes in 10,342 Cases With Hematochezia: CODE BLUE-J Study", "firstAuthor": "Nagata", "multipleAuthors": true, "journal": "Am J Gastroenterol", "year": 2021, "design": "retrospective", "n": 10342, "nField": "reported", "population": "adults hospitalized for sudden rectal bleeding (hematochezia)", "intervention": "colonoscopy to find the source of bleeding", "comparator": "no control group; observational comparison across different bleeding causes", "primaryOutcome": "finding the cause of bleeding and outcomes like rebleeding, death, need for treatment", "result": "Painless bleeding was especially linked to rectal ulcers, hemorrhoids, abnormal blood vessels, radiation colitis, and diverticulosis, while colonoscopy found a cause in 94.9% of cases, most often diverticular bleeding.", "resultDirection": "unclear", "quality": "moderate", "qualityWhy": "Large multi-hospital study, but it only looked back at past cases rather than following patients forward in a controlled way.", "directness": "direct", "limitations": "Retrospective design across many hospitals, so data quality and management may have varied; abstract does not mention blinding or adjustment for confounders.", "followUp": "", "plainFinding": "Painless bleeding often from ulcers, hemorrhoids, vessels, diverticula.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34388140/", "sourceText": "INTRODUCTION: The bleeding source of hematochezia is unknown without performing colonoscopy. We sought to identify whether colonoscopy is a risk-stratifying tool to identify etiology and predict outcomes and whether presenting symptoms can differentiate the etiologies in patients with hematochezia. METHODS: This multicenter retrospective cohort study conducted at 49 hospitals across Japan analyzed 10,342 patients admitted for outpatient-onset acute hematochezia. RESULTS: Patients were mostly elderly population, and 29.5% had hemodynamic instability. Computed tomography was performed in 69.1% and colonoscopy in 87.7%. Diagnostic yield of colonoscopy reached 94.9%, most frequently diverticular bleeding. Thirty-day rebleeding rates were significantly higher with diverticulosis and small bowel bleeding than with other etiologies. In-hospital mortality was significantly higher with angioectasia, malignancy, rectal ulcer, and upper gastrointestinal bleeding. Colonoscopic treatment rates were significantly higher with diverticulosis, radiation colitis, angioectasia, rectal ulcer, and postendoscopy bleeding. More interventional radiology procedures were needed for diverticulosis and small bowel bleeding. Etiologies with favorable outcomes and low procedure rates were ischemic colitis and infectious colitis. Higher rates of painless hematochezia at presentation were significantly associated with multiple diseases, such as rectal ulcer, hemorrhoids, angioectasia, radiation colitis, and diverticulosis. The same was true in cases of hematochezia with diarrhea, fever, and hemodynamic instability. DISCUSSION: This nationwide data set of acute hematochezia highlights the importance of colonoscopy in accurately detecting bleeding etiologies that stratify patients at high or low risk of adverse outcomes and those who will likely require more procedures. Predicting different bleeding etiologies based on initial presentation would be challenging.", "provenance": [ { "field": "n", "quote": "analyzed 10,342 patients admitted for outpatient-onset acute hematochezia" }, { "field": "population", "quote": "patients admitted for outpatient-onset acute hematochezia" }, { "field": "intervention", "quote": "Diagnostic yield of colonoscopy reached 94.9%, most frequently diverticular bleeding." }, { "field": "comparator", "quote": "multicenter retrospective cohort study conducted at 49 hospitals across Japan analyzed 10,342 patients admitted for outpatient-onset acute hematochezia" }, { "field": "primaryOutcome", "quote": "Diagnostic yield of colonoscopy reached 94.9%, most frequently diverticular bleeding." }, { "field": "result", "quote": "Higher rates of painless hematochezia at presentation were significantly associated with multiple diseases, such as rectal ulcer, hemorrhoids, angioectasia, radiation colitis, and diverticulosis." } ] }, { "id": "pmid:34252643", "pmid": "34252643", "doi": "10.1016/j.ijscr.2021.106165", "nctId": null, "pmcid": "PMC8278421", "title": "Rare cause of painless lower gastrointestinal bleeding: A case report", "firstAuthor": "Alyahyawi", "multipleAuthors": false, "journal": "Int J Surg Case Rep", "year": 2021, "design": "case-series", "n": 1, "nField": "reported", "population": "44-year-old woman with intermittent painless rectal bleeding for three months, no other symptoms", "intervention": "surgical removal of part of the colon (ileocecal resection) for intestinal endometriosis", "comparator": "none", "primaryOutcome": "cause of painless rectal bleeding and outcome after surgery", "result": "bleeding was caused by intestinal endometriosis; patient recovered after surgical removal of the affected bowel segment", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common this cause is or whether surgery generally helps others.", "directness": "direct", "limitations": "single case report with no comparison group; findings may not generalize to other patients with painless rectal bleeding.", "followUp": "", "plainFinding": "Rare bowel endometriosis caused bleeding; surgery fixed it.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34252643/", "sourceText": "INTRODUCTION AND IMPORTANCE: Endometriosis is a complex disease in which an abnormal uterine lining-like estrogen-dependent cells settle outside the uterine cavity. Gastrointestinal tract is the commonly affected region in extragenital endometriosis. CASE PRESENTATION: A 44-year-old female patient suffering from intermittent hematochezia for the past three months was presented with no medical history or any other symptoms correlating with current complaints. Clinical examination showed the patient in good condition with soft abdomen without evidence of tenderness or palpable mass or any sign of haemorrhoids or fissures. Initial abdominal sonography revealed a 20 × 25 mm hypoechoic change in caecal region. Colonoscopic biopsies and histopathological examination revealed only colon mucosa with mucosal oedema and an unspecific inflammatory reactive regenerative polypoid with no evidence of tumor tissue adenoma. Intermittent hematochezia of the patient got worse in the following months without any other concurrent symptom. Laparoscopically assisted ileocecal resection with a sutured side-to-side ileoascendostomy was then performed. The patient was kept on enhanced recovery program and was discharged on the fourth post-operative day with analgesics. CLINICAL DISCUSSION: Patients who present with diagnostic challenges or fails to respond to initial treatments for alternative gastrointestinal diagnoses (e.g., IBS), should be analyzed for endometriosis especially in patients with a history or risk factors including nulliparity, early menarche, haematocolpos, retrograde menstruation or even positive family history. CONCLUSION: Endometriosis must be considered as a gastrointestinal pathology as much as gynecological one, and the gastrointestinal surgeons and physicians should be aware of its symptoms or presentation.", "provenance": [ { "field": "population", "quote": "A 44-year-old female patient suffering from intermittent hematochezia for the past three months was presented with no medical history or any other symptoms correlating with current complaints." }, { "field": "intervention", "quote": "Laparoscopically assisted ileocecal resection with a sutured side-to-side ileoascendostomy was then performed." }, { "field": "comparator", "quote": "Colonoscopic biopsies and histopathological examination revealed only colon mucosa with mucosal oedema and an unspecific inflammatory reactive regenerative polypoid with no evidence of tumor tissue adenoma." }, { "field": "primaryOutcome", "quote": "Intermittent hematochezia of the patient got worse in the following months without any other concurrent symptom." }, { "field": "result", "quote": "The patient was kept on enhanced recovery program and was discharged on the fourth post-operative day with analgesics." }, { "field": "n", "quote": "A 44-year-old female patient suffering from intermittent hematochezia for the past three months" } ] }, { "id": "pmid:33596710", "pmid": "33596710", "doi": "10.1177/2324709621994383", "nctId": null, "pmcid": "PMC7897807", "title": "Severe Acute Colonic Diverticular Bleeding: The Efficacy of Rapid Bowel Preparation With 1 L Polyethylene Glycol Ascorbate Solution and Direct Endoscopic Hemoclipping for Successful Hemostasis", "firstAuthor": "Malik", "multipleAuthors": true, "journal": "J Investig Med High Impact Case Rep", "year": 2021, "design": "case-series", "n": null, "nField": "not-reported", "population": "people with severe sudden bleeding from colon diverticula (pouches)", "intervention": "fast bowel-cleansing with a low-volume laxative drink plus endoscopic clipping with epinephrine", "comparator": "traditional higher-volume bowel prep", "primaryOutcome": "stopping the bleeding (hemostasis) and successful colonoscopy visualization", "result": "the rapid prep and clipping approach appeared to help achieve hemostasis, but authors say its exact necessity remains unclear", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a case report/case series describing technique, not a controlled study, so it cannot reliably show whether the treatment works.", "directness": "indirect", "limitations": "no control group, small case-based evidence, authors state the importance of the bowel prep for hemostasis 'remains elusive'", "followUp": "", "plainFinding": "Painless bleeding from diverticula, described technique only.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33596710/", "sourceText": "Colonic diverticular bleeding is an established cause of painless acute lower gastrointestinal hemorrhage. Colonoscopy, performed within 24 hours of presentation, is the usual initial diagnostic procedure in such patients. In order to improve the diagnostic and therapeutic yield of urgent colonoscopy, adequate colon cleansing is required in patients with signs and symptoms of ongoing bleeding. We hereby delineate the importance of rapid bowel preparation with a very-low-volume novel 1 L polyethylene glycol ascorbate solution in the setting of acute severe colonic diverticular bleeding. The 1-L regimen may demonstrate similar efficacy to that of traditional higher volume preparations and it can substantially reduce the time for bowel preparation. Therefore, it can be considered for bowel purge when colonoscopy has to be rapidly planned in critical patients. This article further illustrates that the endoscopic technique using epinephrine followed by direct hemoclipping may be added to the armamentarium for acute colonic diverticular hemorrhage as the first treatment, especially in elderly patients with multiple comorbid conditions. While ample evidence surrounding the efficacy of the clipping method persists in the literature, rapid bowel preparation with 1 L polyethylene glycol ascorbate solution's imperativeness to achieve hemostasis with direct hemoclipping remains elusive.", "provenance": [ { "field": "population", "quote": "Colonic diverticular bleeding is an established cause of painless acute lower gastrointestinal hemorrhage." }, { "field": "intervention", "quote": "rapid bowel preparation with a very-low-volume novel 1 L polyethylene glycol ascorbate solution" }, { "field": "intervention", "quote": "endoscopic technique using epinephrine followed by direct hemoclipping" }, { "field": "comparator", "quote": "The 1-L regimen may demonstrate similar efficacy to that of traditional higher volume preparations" }, { "field": "primaryOutcome", "quote": "rapid bowel preparation with 1 L polyethylene glycol ascorbate solution's imperativeness to achieve hemostasis with direct hemoclipping remains elusive" }, { "field": "result", "quote": "rapid bowel preparation with 1 L polyethylene glycol ascorbate solution's imperativeness to achieve hemostasis with direct hemoclipping remains elusive" } ] }, { "id": "pmid:33397878", "pmid": "33397878", "doi": null, "nctId": null, "pmcid": null, "title": "Giant Villous Adenoma: A Rare Case of Colorectal Adenoma that Mimic Colorectal Cancer", "firstAuthor": "Ferdaus", "multipleAuthors": true, "journal": "Mymensingh Med J", "year": 2021, "design": "case-series", "n": 1, "nField": "reported", "population": "65-year-old woman with long-term painless rectal bleeding and mucus discharge", "intervention": "surgical removal of rectal polyp (low anterior resection with coloanal anastomosis and ileostomy)", "comparator": "none", "primaryOutcome": "diagnosis and resolution of symptoms after surgery", "result": "Large benign rectal polyp (villous adenoma) found and removed; patient became symptom-free", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how common this cause is or how well treatment works in general.", "directness": "direct", "limitations": "Only one patient described; no comparison group; findings may not generalize.", "followUp": "two months after ileostomy reversal, patient asymptomatic", "plainFinding": "Rare large polyp caused bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33397878/", "sourceText": "Colorectal cancer being the 4th most common cause of cancer death in which most arise from a preexisting adenomatous polyp. Among the various adenomas Giant villous adenoma (GVA) is less common. We came across a 65 years female with intermittent per rectal mucus discharge for last 10 years and intermittent fresh, painless, scanty per rectal bleeding along with weakness and fatigue for last 5 years. No members of her family had been suffering from colorectal malignancy. DRE revealed irregular gritty feelings of rectal mucosa starting 2cm from anal verge and the examining fingertip was blood tinged mixed with mucus. On proctoscopic examination the accessible rectum was studded with thousands of polyps with granular appearance, with variable sizes and there was mucus mixed blood within the rectum. Colonoscopy reveals- polypoid lesion starting 2cm from anal verge and extends up to 2cm with granular and velvety appearance. Biopsy was done 2 times for suspicious lesion and histopathology reveals tubulovillous adenoma with dysplasia. However as clinical suspicion of an adenocarcinoma was strong but histopathological report of colonoscopic biopsy was contradictory, intersphincteric ultra-low anterior resection with coloanal anastomosis with covering ileostomy was done. Resected specimen was sent for histopathological study and it reveals- villous adenoma with low grade dysplasia. Two months later reversal of ileostomy was done and now the patient is under regular follow up and now she is asymptomatic.", "provenance": [ { "field": "n", "quote": "a 65 years female" }, { "field": "population", "quote": "intermittent fresh, painless, scanty per rectal bleeding along with weakness and fatigue for last 5 years" }, { "field": "intervention", "quote": "intersphincteric ultra-low anterior resection with coloanal anastomosis with covering ileostomy was done" }, { "field": "primaryOutcome", "quote": "Resected specimen was sent for histopathological study and it reveals- villous adenoma with low grade dysplasia" }, { "field": "result", "quote": "now the patient is under regular follow up and now she is asymptomatic" }, { "field": "comparator", "quote": "intersphincteric ultra-low anterior resection with coloanal anastomosis with covering ileostomy was done" } ] }, { "id": "pmid:33087033", "pmid": "33087033", "doi": "10.2174/1574887115666201021150144", "nctId": null, "pmcid": null, "title": "Conservative Treatment of Hemorrhoidal Disease", "firstAuthor": "Stratta", "multipleAuthors": true, "journal": "Rev Recent Clin Trials", "year": 2021, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoidal disease (hemorrhoids)", "intervention": "conservative treatments: diet/lifestyle changes, oral medications, and topical medications", "comparator": "", "primaryOutcome": "control of symptoms and effectiveness of treatment", "result": "conservative treatment helps most patients with early-stage hemorrhoids, but evidence quality is weak", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a narrative review admitting very few randomized trials exist and most evidence comes from uncontrolled case series.", "directness": "direct", "limitations": "the abstract states few randomized controlled trials exist and most studies are uncontrolled case series, with calls for larger better-designed studies", "followUp": "", "plainFinding": "Hemorrhoids are common, usually painless bleeding cause", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/33087033/", "sourceText": "BACKGROUND: Hemorrhoids are vascular cushions underlying the distal rectal mucosa and contributing to approximately 15-20% of the resting anal pressure with a complete closure of the anal canal. They can become pathological (hemorrhoidal disease, HD) being the most common cause of painless rectal bleeding during defecation with or without prolapsing anal tissue. The treatment of HD must be tailored to both the severity of disease and patient's expectation. METHODS: A narrative review of all the most relevant papers present on the three major databases (PUBMED, EMBASE and WEB OF SCIENCE) regarding conservative treatment was conducted. RESULTS: Conservative treatment is effective in managing the majority of patients complaining of early stages of the disease. Dietary and lifestyle modifications are the first therapeutic step necessary to achieve a regular defecation with soft stool whereas oral phlebotonic drugs can help to control symptoms. The use of topical medications, particularly during the acute phase or in the post-operative period can also be beneficial for all patients complaining of HD. CONCLUSION: Despite a large number of available products in the market and the high incidence of HD, very few randomized controlled trials have been carried out and most of the studies are uncontrolled case series. Larger and better designed studies are necessary to establish the real benefit of all types of drugs for the treatment of early stages of HD.", "provenance": [ { "field": "population", "quote": "patients complaining of early stages of the disease" }, { "field": "intervention", "quote": "Dietary and lifestyle modifications are the first therapeutic step necessary to achieve a regular defecation with soft stool whereas oral phlebotonic drugs can help to control symptoms. The use of topical medications" }, { "field": "result", "quote": "Conservative treatment is effective in managing the majority of patients complaining of early stages of the disease." }, { "field": "result", "quote": "very few randomized controlled trials have been carried out and most of the studies are uncontrolled case series" }, { "field": "primaryOutcome", "quote": "the most common cause of painless rectal bleeding during defecation with or without prolapsing anal tissue" } ] }, { "id": "pmid:32866137", "pmid": "32866137", "doi": "10.12659/AJCR.925673", "nctId": null, "pmcid": "PMC7483500", "title": "Good Outcome of Early-Stage Rectal Cancer Diagnosed During Pregnancy", "firstAuthor": "Alkhamis", "multipleAuthors": true, "journal": "Am J Case Rep", "year": 2020, "design": "case-series", "n": 1, "nField": "reported", "population": "30-year-old pregnant woman at 9 weeks gestation with painless rectal bleeding", "intervention": "sigmoidoscopy with removal of rectal mass (polypectomy)", "comparator": "", "primaryOutcome": "diagnosis and resolution of rectal bleeding, maternal and fetal outcome", "result": "mass removed, diagnosed as early cancer, pregnancy continued bleeding-free with healthy baby born full term", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common this cause is or what usually happens to others with similar symptoms", "directness": "indirect", "limitations": "single case report; findings cannot be generalized to explain typical causes of painless rectal bleeding", "followUp": "full term pregnancy", "plainFinding": "Rare case: early rectal cancer found, successfully removed", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32866137/", "sourceText": "BACKGROUND Colorectal cancer (CRC) in pregnancy is very rare. It is often associated with poor prognosis which is contributed to delayed diagnosis due to the overlapping symptoms of CRC and pregnancy. The purpose of this case report is to highlight the importance of early diagnosis and treatment of CRC in a young pregnant patient with good maternal and fetal outcomes. CASE REPORT A 30-year-old patient, gravida 3, presented at 9-week gestation with a history of sudden painless, fresh, rectal bleeding with no aggravating factors such as constipation or hemorrhoids. Sigmoidoscopy showed a small fungating, intramural mass, 40 cm from the anal verge, which easily bled upon touch. The rest of the colon up to the terminal ilium was normal. The mass was completely removed during the sigmoidoscopy procedure, and the histopathological diagnosis was a tubulovillous adenoma with focal intramucosal carcinoma. After the polypectomy procedure, the patient had an uneventful, bleeding-free pregnancy and delivered a healthy baby at full term. The sigmoidoscopy procedure was considered to be both diagnostic and therapeutic since the entire mass was completely removed. CONCLUSIONS Early diagnosis and intervention are critical in improving the overall outcome of CRC in pregnancy and requires a high index of clinical suspicion. Taking a detailed patient history, exercising attentiveness, and conducting thorough investigations of all symptomatic pregnant women are recommended. Treatment options should involve a multidisciplinary team with consideration to the patient's own choices.", "provenance": [ { "field": "population", "quote": "A 30-year-old patient, gravida 3, presented at 9-week gestation with a history of sudden painless, fresh, rectal bleeding with no aggravating factors such as constipation or hemorrhoids." }, { "field": "intervention", "quote": "The mass was completely removed during the sigmoidoscopy procedure" }, { "field": "primaryOutcome", "quote": "the histopathological diagnosis was a tubulovillous adenoma with focal intramucosal carcinoma" }, { "field": "result", "quote": "After the polypectomy procedure, the patient had an uneventful, bleeding-free pregnancy and delivered a healthy baby at full term." }, { "field": "n", "quote": "A 30-year-old patient, gravida 3" } ] }, { "id": "pmid:32358354", "pmid": "32358354", "doi": "10.1097/MD.0000000000019836", "nctId": null, "pmcid": "PMC7440348", "title": "Acute hemorrhagic rectal ulcer: Experience in 11 patients at an urban acute care center in the USA: A case series", "firstAuthor": "Sugawa", "multipleAuthors": true, "journal": "Medicine (Baltimore)", "year": 2020, "design": "case-series", "n": 11, "nField": "reported", "population": "elderly, bedridden hospital patients with major underlying illnesses and sudden painless rectal bleeding", "intervention": "endoscopic diagnosis and treatment of acute hemorrhagic rectal ulcer", "comparator": "none", "primaryOutcome": "control of bleeding and survival after diagnosis of acute hemorrhagic rectal ulcer", "result": "All 11 needed blood transfusions; 7 improved with transfusion alone, 4 needed endoscopic treatment to stop bleeding; 3 died within a month from other illnesses, not bleeding; the 8 survivors had no further bleeding", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "This is a small descriptive case series of only 11 patients from one hospital with no comparison group, so it cannot show whether treatments worked better than no treatment.", "directness": "direct", "limitations": "Small sample size from a single center; no control group; descriptive case series design.", "followUp": "within a month", "plainFinding": "Painless bleeding from a rectal ulcer in frail elderly patients", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32358354/", "sourceText": "INTRODUCTION: Acute hemorrhagic rectal ulcer (AHRU) is a rare entity which has most frequently been described in Japan and Taiwan literature. This study characterizes 11 AHRUs identified and managed at an urban acute care hospital in the United States of America (USA). METHODS: A total of 2253 inpatients underwent colonoscopy. In 1172 patients (52%), colonoscopy was performed for evaluation of lower gastrointestinal (LGI) bleeding. Eleven (0.9%) of the 1172 patients with LGI bleeding had AHRU. RESULTS: AHRU is characterized by a sudden onset of painless and massive lower rectal bleeding in elderly, bedridden patients (pts) with major underlying diseases. The endoscopic findings were classified into 4 types. All 11 ulcers were located in the distal rectum within 10 cm of the dentate line. All 11 patients required blood transfusion (mean = 3.7 units; range 2-9 units). Seven patients responded to blood, plasma, and platelet transfusions. The other 4 patients required endoscopic hemostasis.Three patients died within a month of colonoscopy from comorbidities. None had bleeding as a cause of death. Eight surviving patients did not have recurrent bleeding. CONCLUSION: AHRU does exist in the USA and should be considered as an important cause of acute lower GI bleeding in elderly, critically ill, and bedridden patients. AHRU should be recognized and managed correctly.", "provenance": [ { "field": "n", "quote": "Eleven (0.9%) of the 1172 patients with LGI bleeding had AHRU." }, { "field": "population", "quote": "AHRU is characterized by a sudden onset of painless and massive lower rectal bleeding in elderly, bedridden patients (pts) with major underlying diseases." }, { "field": "intervention", "quote": "The other 4 patients required endoscopic hemostasis." }, { "field": "comparator", "quote": "Seven patients responded to blood, plasma, and platelet transfusions." }, { "field": "primaryOutcome", "quote": "Three patients died within a month of colonoscopy from comorbidities. None had bleeding as a cause of death. Eight surviving patients did not have recurrent bleeding." }, { "field": "result", "quote": "All 11 patients required blood transfusion (mean = 3.7 units; range 2-9 units). Seven patients responded to blood, plasma, and platelet transfusions. The other 4 patients required endoscopic hemostasis." } ] }, { "id": "pmid:32000450", "pmid": "32000450", "doi": "10.1097/MD.0000000000019028", "nctId": null, "pmcid": "PMC7004677", "title": "Primary anorectal malignant melanoma: A case report", "firstAuthor": "Xu", "multipleAuthors": true, "journal": "Medicine (Baltimore)", "year": 2020, "design": "case-series", "n": 1, "nField": "reported", "population": "66-year-old man with 2 months of painless rectal bleeding", "intervention": "Surgery to remove the rectum and anus (abdominoperineal resection)", "comparator": "No comparator (single case)", "primaryOutcome": "Whether cancer came back after surgery", "result": "Diagnosed with a rare malignant melanoma of the anus/rectum; after surgery, no cancer recurrence at 24 months", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show what causes painless rectal bleeding in general or whether this treatment works for others.", "directness": "indirect", "limitations": "Single case report with no comparison group; findings may not generalize to other causes of painless rectal bleeding.", "followUp": "24 month", "plainFinding": "Rare melanoma found; surgery worked for one patient", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32000450/", "sourceText": "INTRODUCTION: Anorectal malignant melanoma (AMM) is a rare and aggressive malignance with poor prognosis, yet no consensus of treatment exists to date. Abdominoperineal resection surgery (APR) is the standard treatment of anorectal malignant melanoma, capable of controlling lymphatic spread and obtaining a large negative margin for local control but it can lead to complications. Wide local excision (WLE) allows for quicker recovery and has minimal impact on bowel function (i.e., bypassing the need for a stoma). PATIENT CONCERNS: A 66-year-old male patient presented with a 2-months history of painless rectal bleeding. DIAGNOSIS: The characteristic finding from colonoscopy and magnetic resonance imaging led to a diagnosis of colorectal cancer. Immunohistochemistry analyses confirmed malignant melanoma. The tumor was classified as: HMB-45(+), S-100(+), CD117(±), PCK(-), ki-67(+, 10%). INTERVENTIONS: The patient underwent abdominoperineal resection with no other adjuvant therapy. OUTCOMES: The patient is doing well at 24 month after the operation, with no signs of recurrence. CONCLUSION: AMM is a rare malignance, and is easy to misdiagnose. The therapy approach remains controversial. Every effort should be made to ensure prompt diagnosis and to define the optimally effective standard therapy approach.", "provenance": [ { "field": "population", "quote": "A 66-year-old male patient presented with a 2-months history of painless rectal bleeding." }, { "field": "intervention", "quote": "The patient underwent abdominoperineal resection with no other adjuvant therapy." }, { "field": "comparator", "quote": "The patient underwent abdominoperineal resection with no other adjuvant therapy." }, { "field": "primaryOutcome", "quote": "The patient is doing well at 24 month after the operation, with no signs of recurrence." }, { "field": "result", "quote": "Immunohistochemistry analyses confirmed malignant melanoma." }, { "field": "result", "quote": "The patient is doing well at 24 month after the operation, with no signs of recurrence." }, { "field": "n", "quote": "A 66-year-old male patient presented" }, { "field": "followUp", "quote": "at 24 month after the operation" } ] }, { "id": "pmid:31857682", "pmid": "31857682", "doi": "10.1038/s41379-019-0437-z", "nctId": null, "pmcid": null, "title": "A novel group of HPV-related adenocarcinomas of the lower anogenital tract (vagina, vulva, and anorectum) in women and men resembling HPV-related endocervical adenocarcinomas", "firstAuthor": "Voltaggio", "multipleAuthors": true, "journal": "Mod Pathol", "year": 2020, "design": "case-series", "n": 9, "nField": "reported", "population": "men and women with rare HPV-related adenocarcinomas of the vagina, vulva, or anorectal area", "intervention": "none; this is a descriptive pathology study with no treatment tested", "comparator": "none", "primaryOutcome": "clinical presentation and tumor characteristics, including symptoms like bleeding", "result": "Some patients with anorectal tumors had painless rectal bleeding as their presenting symptom, linked to HPV-positive adenocarcinoma", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "It is a small case series of only nine patients with no control group, so it cannot show how common this cause of bleeding is or compare treatments.", "directness": "indirect", "limitations": "Very small sample size, no comparison group, and follow-up data available for only five of nine patients.", "followUp": "", "plainFinding": "Rare HPV cancer caused painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31857682/", "sourceText": "Human papillomavirus (HPV) is an oncogenic virus associated with the development of several human cancers. Primary vaginal, vulvar, and anal adenocarcinomas are rare and, to date, have rarely been shown to be associated with HPV infection. We report a series of nine HPV-related adenocarcinomas of the lower anogenital tract distal to the cervix. The tumors involved the vagina (4), anorectum (3), and vulva (2). Two of the three anorectal cases involved men. Patients presented with a vulvar or vaginal mass/nodule, painless rectal bleeding, or during screening colonoscopy. Lesions ranged in size from 3.2 to 8.4 cm. The most salient morphologic characteristic was the presence of papillary or villiform/villoglandular architecture in all cases. Tumors displayed features similar to those of usual type high-risk HPV-related endocervical adenocarcinoma, namely, mucinous or mucin-poor (pseudoendometrioid) features or a hybrid of these, with columnar cells with crowded, cigar-shaped to ovoid irregular nuclei. Mitoses (mostly apical) and apoptotic bodies were easily identified. Adenosis was present in two vaginal cases. One anal tumor featured abundant intracytoplasmic mucin that was multivacuolated in some areas imparting a \"clear cell\"-like appearance. All tumors were diffusely and strongly positive for p16. Seven of seven tested cases were positive for high-risk HPV by in situ hybridization or polymerase chain reaction. Follow-up information, available in five patients, revealed two local recurrences but no tumor related deaths or distant metastases. We report the first well-documented series of HPV-associated primary adenocarcinomas of the vagina, vulva, and anorectum and broaden the spectrum of HPV-related neoplasia involving the lower anogenital tract in both women and men.", "provenance": [ { "field": "n", "quote": "We report a series of nine HPV-related adenocarcinomas of the lower anogenital tract distal to the cervix." }, { "field": "population", "quote": "Two of the three anorectal cases involved men." }, { "field": "intervention", "quote": "We report the first well-documented series of HPV-associated primary adenocarcinomas of the vagina, vulva, and anorectum" }, { "field": "comparator", "quote": "We report a series of nine HPV-related adenocarcinomas of the lower anogenital tract distal to the cervix." }, { "field": "primaryOutcome", "quote": "Patients presented with a vulvar or vaginal mass/nodule, painless rectal bleeding, or during screening colonoscopy." }, { "field": "result", "quote": "Patients presented with a vulvar or vaginal mass/nodule, painless rectal bleeding, or during screening colonoscopy." } ] }, { "id": "pmid:31633727", "pmid": "31633727", "doi": "10.1590/S0004-2803.201900000-54", "nctId": null, "pmcid": null, "title": "CLINICAL UTILITY OF RISK SCORES IN VARICEAL BLEEDING", "firstAuthor": "Chandnani", "multipleAuthors": true, "journal": "Arq Gastroenterol", "year": 2019, "design": "prospective-cohort", "n": 300, "nField": "reported", "population": "patients with upper gastrointestinal bleeding, including those with and without esophageal varices", "intervention": "four risk scoring systems (AIMS65, Rockall, Glasgow Blatchford, PNED) used to predict outcomes", "comparator": "patients with non-variceal upper GI bleeding", "primaryOutcome": "predicting death, rebleeding, need for blood transfusion, or need for procedures within 30 days", "result": "each score predicted only some outcomes, not all, and none worked well across the board", "resultDirection": "mixed", "quality": "low", "qualityWhy": "it is an observational study validating prediction scores, not a treatment trial, and no factor was significant after adjusting for other factors", "directness": "indirect", "limitations": "abstract states no factor was significant on multivariate analysis, and this study is about predicting outcomes in known variceal bleeding, not about explaining painless rectal bleeding in general", "followUp": "30 days", "plainFinding": "Painless bleeding linked to variceal cause", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31633727/", "sourceText": "BACKGROUND: Variceal bleeding remains important cause of upper gastrointestinal bleed. Various risk scores are used in risk stratification for non-variceal bleed. Their utility in variceal bleeding patients is not clear. This study aims to compare probability of these scores in predicting various outcomes in same population. OBJECTIVE: This study aims to compare probability of these scores in predicting various outcomes in same population. To study characteristics and validate AIMS65, Rockall, Glasgow Blatchford score(GBS), Progetto Nazionale Emorragia Digestiva (PNED) score in variceal Upper Gastrointestinal Bleed (UGIB) patients for predicting various outcomes in our population. METHODS: Three hundred subjects with UGIB were screened prospectively. Of these 141 patients with variceal bleeding were assessed with clinical, blood investigations and endoscopy and risk scores were calculated and compared to non-variceal cases. All cases were followed up for 30 days for mortality, rebleeding, requirement of blood transfusion and need of radiological or surgical intervention. RESULTS: Variceal bleeding (141) was more common than non variceal (134) and 25 had negative endoscopy. In variceal group, cirrhosis (85%) was most common etiology. Distribution of age and sex were similar in both groups. Presence of coffee coloured vomitus (P=0.002), painless bleed (P=0.001), edema (P=0.001), ascites (P=0.001), hemoglobin <7.5 gms (P<0.001), pH<7.35 (P<0.001), serum bicarbonate level <17.6 mmol/L (P<0.001), serum albumin<2.75 gms% (P<0.001), platelet count <1.2 lacs/µL (P<0.001), high INR 1.35 (P<0.001), BUN >25mmol/L (P<0.001), and ASA status (P<0.001), high lactate >2.85 mmol/L (P=0.001) were significant. However, no factor was found significant on multivariate analysis. Rockall was found to be significant in predicting mortality and rebleed. AIMS65 was also significant in predicting mortality. GBS was significant in predicting blood transfusion and need of intervention. PNED score was significant in all events except mortality. CONCLUSION: All four scores had lower predictive potential in predicting events in variceal bleed. However, AIMS65 & Rockall score were significant in predicting mortality, while GBS in predicting need of transfusion and intervention. PNED score was significant in all events except mortality.", "provenance": [ { "field": "n", "quote": "Three hundred subjects with UGIB were screened prospectively" }, { "field": "population", "quote": "Of these 141 patients with variceal bleeding were assessed with clinical, blood investigations and endoscopy and risk scores were calculated and compared to non-variceal cases" }, { "field": "intervention", "quote": "validate AIMS65, Rockall, Glasgow Blatchford score(GBS), Progetto Nazionale Emorragia Digestiva (PNED) score in variceal Upper Gastrointestinal Bleed (UGIB) patients for predicting various outcomes" }, { "field": "comparator", "quote": "risk scores were calculated and compared to non-variceal cases" }, { "field": "primaryOutcome", "quote": "followed up for 30 days for mortality, rebleeding, requirement of blood transfusion and need of radiological or surgical intervention" }, { "field": "result", "quote": "All four scores had lower predictive potential in predicting events in variceal bleed. However, AIMS65 & Rockall score were significant in predicting mortality, while GBS in predicting need of transfusion and intervention. PNED score was significant in all events except mortality." }, { "field": "plainFinding", "quote": "Presence of coffee coloured vomitus (P=0.002), painless bleed (P=0.001)" } ] }, { "id": "pmid:31599855", "pmid": "31599855", "doi": "10.1097/MPH.0000000000001614", "nctId": null, "pmcid": null, "title": "Constitutional Mismatch Repair Gene Defect Syndrome Presenting With Adenomatous Polyposis and Cafe au Lait Spots: A Case Report", "firstAuthor": "Sağ", "multipleAuthors": true, "journal": "J Pediatr Hematol Oncol", "year": 2020, "design": "case-series", "n": 1, "nField": "reported", "population": "16-year-old girl with painless rectal bleeding, abdominal pain, and anorexia for a year", "intervention": "none (diagnostic workup and polyp removal)", "comparator": "none", "primaryOutcome": "underlying cause of painless rectal bleeding and colon polyps", "result": "Found to have a genetic mismatch repair gene defect causing multiple colon polyps, one with early cancer changes, eventually requiring colon removal", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report, which cannot show how common this cause is or how it compares to other explanations.", "directness": "direct", "limitations": "Single case report; findings may not generalize to other people with painless rectal bleeding.", "followUp": "2 years", "plainFinding": "Rare genetic disorder caused the bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31599855/", "sourceText": "INTRODUCTION: Adenomatous polyps in the gastrointestinal system rarely occur in childhood and are accompanied by syndromes such as Familial adenomatous polyposis, attenuated familial adenomatous polyposis, and MUTYH-associated polyposis, Gardner and Turcot syndrome, and also mismatch repair (MMR) gene defects. In this article, we want to present a rare patient who had adenomatous polyposis and in situ carcinoma and was detected biallelic MMR gene defect. CASE: A 16-year-old female patient admitted with painless rectal bleeding, chronic abdominal pain, and anorexia for 1 year. Her physical examination was notable for multiple cafe au lait spots. The colonoscopic and histopathologic examination revealed multiple adenomatous polyps that one of them contains low-high grade dysplasia and in situ carsinoma. Genetic analysis revealed a homozygous mutation in the PMS2 gene [c.1164delT (p.H388Qfs*10) (p.His388GInfsTer10)] and she was diagnosed with constitutional MMR gene defect syndrome. Polypectomy was performed 4 times in 2 years period. Then, the patient's last colonoscopic examination revealed a large broad polyp in the rectum and multiple polyps in the other colon segments, and she underwent colectomy because of high risk of colorectal cancer. CONCLUSIONS: Adenomatous polyps are very important in childhood because of rarity. In particular, the presence of cafe au lait spots and a history of malignancy detected in relatives at an early age must be considered for CMMRD.", "provenance": [ { "field": "n", "quote": "A 16-year-old female patient" }, { "field": "population", "quote": "admitted with painless rectal bleeding, chronic abdominal pain, and anorexia for 1 year" }, { "field": "intervention", "quote": "Polypectomy was performed 4 times in 2 years period" }, { "field": "comparator", "quote": "CASE: A 16-year-old female patient admitted with painless rectal bleeding" }, { "field": "primaryOutcome", "quote": "we want to present a rare patient who had adenomatous polyposis and in situ carcinoma and was detected biallelic MMR gene defect" }, { "field": "result", "quote": "Genetic analysis revealed a homozygous mutation in the PMS2 gene [c.1164delT (p.H388Qfs*10) (p.His388GInfsTer10)] and she was diagnosed with constitutional MMR gene defect syndrome" }, { "field": "result", "quote": "she underwent colectomy because of high risk of colorectal cancer" } ] }, { "id": "pmid:31275778", "pmid": "31275778", "doi": "10.7759/cureus.4554", "nctId": null, "pmcid": "PMC6592830", "title": "An Incidental Finding of Anemia: Rectal Adenocarcinoma in a Young Adult", "firstAuthor": "Memon", "multipleAuthors": true, "journal": "Cureus", "year": 2019, "design": "case-series", "n": 1, "nField": "reported", "population": "a 34-year-old man with painless rectal bleeding and anemia", "intervention": "none (diagnostic workup including colonoscopy)", "comparator": "", "primaryOutcome": "", "result": "colonoscopy found an 8 cm mass that was diagnosed as advanced (stage IV) rectal adenocarcinoma", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how common this cause is or apply broadly.", "directness": "direct", "limitations": "Single case report; findings in one patient cannot be generalized to explain all cases of painless rectal bleeding.", "followUp": "", "plainFinding": "Painless bleeding was colon cancer.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/31275778/", "sourceText": "Rectal adenocarcinoma is an uncommon finding in patients under the age of 40. However, epidemiological surveys have suggested that colorectal cancers are increasing in incidence among patients aged 20 to 39 years in the United States. Colorectal adenocarcinoma is often not considered in the differential diagnosis in this demographic because of age. Here, we present the case of an incidental finding of anemia during a preliminary evaluation of rheumatoid arthritis leading to the diagnosis of stage IV-B rectal adenocarcinoma in a 34-year-old male patient. A 34-year-old Caucasian male presented with the incidental finding of anemia during a preliminary evaluation for rheumatoid arthritis. The patient was asymptomatic with the exception of a three-month history of wrist and ankle joint pain. Past medical history was positive for only a three-year history of occasional spotty, painless rectal bleeding attributed to internal hemorrhoids. Physical exam findings were positive for mild extremity pallor and positive fecal occult blood test. Hematologic studies revealed a significant microcytic, hypochromic anemia with severe iron deficiency. Laboratory studies revealed no evidence of vitamin deficiency, hemolytic activity, hematuria, hypothyroidism, or clotting factor disorder. Erythrocyte sedimentation rate (ESR), rheumatoid factor, and cyclic citrullinated peptide 3 (CCP3) were elevated supporting the diagnosis of underlying rheumatoid arthritis. On further questioning, the patient revealed that he had been utilizing an average of 2000 mg of ibuprofen daily during the previous several months in an attempt to control his joint pain. The patient was evaluated for a potential upper gastrointestinal bleed by esophagogastroduodenoscopy (EGD), which found no evidence of active bleeding. As the patient continued to have decreasing hemoglobin levels, he was evaluated for a lower gastrointestinal source of bleeding by colonoscopy, which revealed an 8 cm circumferential mass at the anal verge. Pathological evaluation of biopsy samples revealed a moderately differentiated invasive adenocarcinoma. The patient had no family history of colorectal cancer or major associated risk factors, such as obesity, smoking history, heavy alcohol use, diabetes mellitus type 2, or a history of inflammatory bowel disease. Following discharge, positron emission tomography (PET) scan showed extensive metastatic disease to multiple regional lymph nodes as well as multiple suspicious hepatic lesions and bilateral pulmonary nodules. Due to the poor prognosis, recommended treatment consisted of folinic acid, 5-fluorouracil, oxaliplatin (FOLFOX-4) along with palliative radiation. The cause of the increase in the incidence rate of colorectal cancer in young adults remains unknown. Among this demographic, colorectal cancers appear to be more aggressive and present at later stages with more advanced disease. In young adults, the most common clinical sign at presentation is rectal bleeding. In young adults presenting with seemingly common gastrointestinal complaints, a high degree of suspicion for colorectal cancer may be warranted by clinicians.", "provenance": [ { "field": "population", "quote": "A 34-year-old Caucasian male presented with the incidental finding of anemia during a preliminary evaluation for rheumatoid arthritis." }, { "field": "population", "quote": "Past medical history was positive for only a three-year history of occasional spotty, painless rectal bleeding attributed to internal hemorrhoids." }, { "field": "intervention", "quote": "he was evaluated for a lower gastrointestinal source of bleeding by colonoscopy, which revealed an 8 cm circumferential mass at the anal verge." }, { "field": "result", "quote": "Pathological evaluation of biopsy samples revealed a moderately differentiated invasive adenocarcinoma." }, { "field": "n", "quote": "a 34-year-old male patient" } ] }, { "id": "pmid:30976892", "pmid": "30976892", "doi": "10.1007/s00104-019-0950-0", "nctId": null, "pmcid": null, "title": "[Endoscopy, angiography, surgery: diagnostic and therapeutic algorithms for diverticular bleeding]", "firstAuthor": "Schwenk", "multipleAuthors": false, "journal": "Chirurg", "year": 2019, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with diverticular disease who have painless rectal bleeding", "intervention": "diagnostic workup with endoscopy, angiography, or CT angiography, followed by endoscopic, radiological, or surgical treatment if needed", "comparator": "not applicable - review of diagnostic and treatment algorithms, no comparison group", "primaryOutcome": "identifying the source of bleeding and stopping it", "result": "most diverticular bleeding stops on its own, and when it doesn't, endoscopy can usually find and treat the source; surgery is reserved for severe or recurrent cases", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a narrative review summarizing expert recommendations and general knowledge, not original research testing an intervention.", "directness": "direct", "limitations": "no original data, patient numbers, or study methodology described; it is a review article based on existing guidelines and literature.", "followUp": "", "plainFinding": "Painless bleeding often from diverticula, usually stops alone.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30976892/", "sourceText": "Diverticular bleeding is a complication of diverticular disease but in contrast to diverticulitis, publications concerning diverticular bleeding are less common. Diverticular bleeding is the cause of approximately 20-50% of cases of lower gastrointestinal bleeding and in rare cases can be life-threatening. The main symptom of diverticular hemorrhage is painless hematochezia and the German guidelines recommend that further diagnostics of suspected diverticular bleeding should be performed in hospital. Interdisciplinary diagnostic and therapeutic algorithms recommend primary endoscopy in acute as well as chronic recurrent diverticular bleeding. If endoscopy fails to provide an exact localization of the origin of bleeding, angiography or computed tomography (CT) angiography can be performed. The 99mTc erythrocyte scintigraphy should only be performed if endoscopy and angiography are unable to identify the localization of the bleeding source. More than 90% of diverticular hemorrhages stop spontaneously; however, it is general agreed that an active diverticular bleeding detected during colonoscopy should be immediately treated endoscopically. Alternative radiological techniques for hemostasis are rarely needed and attention must be paid to the complications. In the rare case of severe bleeding that cannot otherwise be stopped or if the bleeding vessel cannot be located, laparotomy and total colectomy can be recommended. If the diverticular bleeding has definitely been identified or recurrent bleeding causes chronic anemia, segmental or total colectomy may be undertaken; however, the advantages and disadvantages of both types of surgery have to be thoroughly explained to the patient.", "provenance": [ { "field": "population", "quote": "Diverticular bleeding is a complication of diverticular disease" }, { "field": "intervention", "quote": "Interdisciplinary diagnostic and therapeutic algorithms recommend primary endoscopy in acute as well as chronic recurrent diverticular bleeding. If endoscopy fails to provide an exact localization of the origin of bleeding, angiography or computed tomography (CT) angiography can be performed." }, { "field": "comparator", "quote": "The main symptom of diverticular hemorrhage is painless hematochezia" }, { "field": "primaryOutcome", "quote": "further diagnostics of suspected diverticular bleeding should be performed in hospital" }, { "field": "result", "quote": "More than 90% of diverticular hemorrhages stop spontaneously; however, it is general agreed that an active diverticular bleeding detected during colonoscopy should be immediately treated endoscopically." }, { "field": "result", "quote": "In the rare case of severe bleeding that cannot otherwise be stopped or if the bleeding vessel cannot be located, laparotomy and total colectomy can be recommended." } ] }, { "id": "pmid:30902841", "pmid": "30902841", "doi": "10.1136/bcr-2018-227700", "nctId": null, "pmcid": "PMC6453398", "title": "Multiple venous malformations in the left colon and rectum: a long-standing case managed conservatively and an update of current literature", "firstAuthor": "Ganesananthan", "multipleAuthors": true, "journal": "BMJ Case Rep", "year": 2019, "design": "case-series", "n": 1, "nField": "reported", "population": "65-year-old patient with painless rectal bleeding", "intervention": "treatment options discussed for venous malformations of the colon/rectum", "comparator": "previously managed as colitis and angiodysplasia", "primaryOutcome": "diagnosis and management of bleeding source", "result": "patient had venous malformations causing painless bleeding, previously misdiagnosed as colitis and angiodysplasia", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how well treatments generally work.", "directness": "direct", "limitations": "Single case report; diagnosis delayed for years; no comparison group", "followUp": "", "plainFinding": "Rare vein defect caused bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30902841/", "sourceText": "Venous or cavernous malformations of the colon or rectum are a rare cause of lower gastrointestinal bleeds. It has been previously described as a diffuse cavernous haemangioma which was thought to be a benign vascular tumour. It mainly affects the rectosigmoid area of the gastrointestinal tract and is most common in children and young adults. Misdiagnosis is common with patients averaging a total of 19 years delay to this final diagnosis. We report a case of a 65-year-old patient who presented with occult, painless rectal bleeding and prior to this presentation, had been managed variously as colitis and angiodysplasia. This article aims to delineate the updated classification of this disease, principal clinical clues to aid the diagnosis while discussing patient treatment options and potential challenges faced in patient management.", "provenance": [ { "field": "population", "quote": "a 65-year-old patient who presented with occult, painless rectal bleeding" }, { "field": "intervention", "quote": "discussing patient treatment options and potential challenges faced in patient management." }, { "field": "comparator", "quote": "had been managed variously as colitis and angiodysplasia" }, { "field": "primaryOutcome", "quote": "principal clinical clues to aid the diagnosis" }, { "field": "result", "quote": "had been managed variously as colitis and angiodysplasia" }, { "field": "n", "quote": "a 65-year-old patient" } ] }, { "id": "pmid:30739086", "pmid": "30739086", "doi": "10.1136/bcr-2018-226355", "nctId": null, "pmcid": "PMC6441250", "title": "Solitary ascending colon ulcer diagnosed as gastrointestinal CMV disease", "firstAuthor": "Case", "multipleAuthors": true, "journal": "BMJ Case Rep", "year": 2019, "design": "case-series", "n": 1, "nField": "reported", "population": "42-year-old woman on chemotherapy for bile duct cancer, with painless rectal bleeding", "intervention": "", "comparator": "", "primaryOutcome": "cause of painless rectal bleeding", "result": "found a solitary ulcer in the ascending colon caused by CMV infection", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common or typical this cause is.", "directness": "indirect", "limitations": "single case, specific to a chemotherapy patient, cannot generalize to other causes of painless bleeding", "followUp": "", "plainFinding": "Rare viral ulcer caused bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30739086/", "sourceText": "A 42-year-old woman with a history of cholangiocarcinoma on adjuvant chemotherapy with capecitabine presented with painless haematochezia. She was found to have an isolated twenty-five mm ulcer in the ascending colon. Biopsies of the ulceration demonstrated typical cytomegalovirus (CMV) inclusions and her peripheral blood CMV PCR was significantly elevated. This is an unusual case of a solitary proximal colon ulcer. Non-steroidal anti-inflammatory drugs, inflammatory bowel disease and malignancy, are the most frequent causes of isolated ulcers in the proximal colon. Gastrointestinal (GI) CMV disease most commonly causes CMV colitis and is considered rare outside of the transplant population and other severely immunosuppressed patient groups. Patients who have received chemotherapy may also be at risk for GI CMV disease. The diagnosis should be suspected in patients who present with haematochezia or watery diarrhoea within a broad window of time after receiving chemotherapy.", "provenance": [ { "field": "population", "quote": "A 42-year-old woman with a history of cholangiocarcinoma on adjuvant chemotherapy with capecitabine presented with painless haematochezia." }, { "field": "result", "quote": "She was found to have an isolated twenty-five mm ulcer in the ascending colon. Biopsies of the ulceration demonstrated typical cytomegalovirus (CMV) inclusions and her peripheral blood CMV PCR was significantly elevated." }, { "field": "primaryOutcome", "quote": "This is an unusual case of a solitary proximal colon ulcer." }, { "field": "n", "quote": "A 42-year-old woman" } ] }, { "id": "pmid:30577321", "pmid": "30577321", "doi": "10.1016/j.transproceed.2018.05.015", "nctId": null, "pmcid": null, "title": "Gastrointestinal Bleeding Secondary to Iliac Artery Pseudoaneurysm in a Patient With Remote Pancreas Transplant: A Case Report", "firstAuthor": "Ramos", "multipleAuthors": true, "journal": "Transplant Proc", "year": 2018, "design": "case-series", "n": 1, "nField": "reported", "population": "49-year-old man with type 1 diabetes and a pancreas transplant 4 years earlier that had failed", "intervention": "surgery and stenting to fix a bulging artery (pseudoaneurysm) eroding into the bowel connection", "comparator": "no comparator, single patient case", "primaryOutcome": "stopping painless rectal bleeding (hematochezia)", "result": "bleeding was caused by an artery pseudoaneurysm eroding into the pancreas-bowel connection; after balloon and stent treatment, bleeding stopped", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how often this cause applies to others or prove the treatment works in general", "directness": "indirect", "limitations": "only one patient, from a very specific context (prior pancreas transplant with enteric drainage), not generalizable to painless rectal bleeding in general", "followUp": "", "plainFinding": "Rare artery defect caused bleeding; fixed with stenting.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30577321/", "sourceText": "BACKGROUND: Vascular complications represent the most common cause of early graft failure after pancreatic transplantation (PT). Pseudoaneurysms are uncommon vascular complications that usually present within the first year post transplantation. CASE REPORT: A 49-year-old man with history of type 1 diabetes mellitus presented for evaluation with a 2-day history of painless hematochezia. He had undergone PT 4 years prior to presentation, which failed due to acute cellular rejection after 1 year. Both extended upper endoscopy and colonoscopy did not identify an active bleeding source. After an episode of massive hematochezia, he became hemodynamically unstable with peritoneal signs noted on physical examination. An abdominal angiogram was unable to identify active hemorrhage, and the patient was transferred to the operating room for open laparotomy. Exploration revealed a right common iliac artery pseudoaneurysm eroding into the pancreatic-ileal anastomosis, which required initial digital compression for initial hemostasis. After combined endovascular procedure with ballooning and stenting of the right iliac artery, optimal hemostasis was achieved without further episodes of hematochezia. DISCUSSION: Gastrointestinal bleeding (GIB) has been reported to occur in 11% of enteric-drained PT. Even though infectious causes have been reported, culprits are more commonly associated with vascular or enteric surgical anastomosis and usually occur within the early postoperative course. Here we report an uncommon cause of GIB, a late complication of PT, and review important points associated with the management of GIB, anatomy of PT, and potential etiologies for early and late GIB in the setting of PT.", "provenance": [ { "field": "n", "quote": "A 49-year-old man with history of type 1 diabetes mellitus presented for evaluation" }, { "field": "population", "quote": "A 49-year-old man with history of type 1 diabetes mellitus presented for evaluation with a 2-day history of painless hematochezia. He had undergone PT 4 years prior to presentation, which failed due to acute cellular rejection after 1 year." }, { "field": "intervention", "quote": "After combined endovascular procedure with ballooning and stenting of the right iliac artery, optimal hemostasis was achieved without further episodes of hematochezia." }, { "field": "comparator", "quote": "CASE REPORT" }, { "field": "primaryOutcome", "quote": "presented for evaluation with a 2-day history of painless hematochezia" }, { "field": "result", "quote": "Exploration revealed a right common iliac artery pseudoaneurysm eroding into the pancreatic-ileal anastomosis, which required initial digital compression for initial hemostasis. After combined endovascular procedure with ballooning and stenting of the right iliac artery, optimal hemostasis was achieved without further episodes of hematochezia." } ] }, { "id": "pmid:29941389", "pmid": "29941389", "doi": "10.1016/j.euf.2018.06.005", "nctId": null, "pmcid": null, "title": "Antimicrobial Lubricant Did Not Reduce Infection Rate in Transrectal Biopsy Patients in a Large Randomized Trial Due to Low Complication Rates", "firstAuthor": "Salomon", "multipleAuthors": true, "journal": "Eur Urol Focus", "year": 2019, "design": "rct", "n": 732, "nField": "reported", "population": "men undergoing transrectal prostate biopsy", "intervention": "antimicrobial lubricant used during prostate biopsy", "comparator": "standard (non-antimicrobial) lubricant", "primaryOutcome": "infectious complications after prostate biopsy", "result": "no significant reduction in infectious complications with the antimicrobial lubricant; overall complication rates were low, with rectal bleeding in 7.4% of patients", "resultDirection": "no-benefit", "quality": "moderate", "qualityWhy": "it was a large randomized trial, but only 73% of patients returned questionnaires and it was limited to one center, which weakens confidence.", "directness": "indirect", "limitations": "Our results stem from a large German single center and therefore are limited to this patient group.", "followUp": "3-wk", "plainFinding": "No benefit from antimicrobial lubricant; bleeding uncommon", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/29941389/", "sourceText": "BACKGROUND: Transrectal prostate biopsy (pbx) is the most frequent outpatient procedure in the urological field. Septic complications are a major health issue. OBJECTIVE: To evaluate complication rates with or without an antimicrobial lubricant. DESIGN, SETTING, AND PARTICIPANTS: A total of 1000 patients received pbx between 2013 and 2015. Information about complications was collected by a 3-wk questionnaire. Return rate was 73.2% (n=732). INTERVENTION: Randomization for pbx with the instillation of an antimicrobial lubricant (intervention group, n=385) or the standard lubricant (control group, n=347) was performed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariable analyses assessed the association between infectious complications at biopsy and use of an antimicrobial lubricant, International Prostate Symptom Score (IPSS), history of urogenitourinary infections, and several other confounders. RESULTS AND LIMITATIONS: The use of an antimicrobial lubricant did not reduce infection rate. Overall complication rate was very low. Of all patients, 69.3% described the procedure as pain free. Fever ≥38.5°C was reported in overall 1.9% of patients. Urinary retention with catheterization occurred in 3.1%. Most common complications were hematospermia (47.4%), macrohematuria (23.8%), and rectal bleeding (7.4%). Readmission rate was 1% (n=7). In multivariable analyses, IPSS and previous infectious complications were associated with a higher risk of infectious complications. Our results stem from a large German single center and therefore are limited to this patient group. CONCLUSIONS: No significant reduction was shown in infectious complications in the intervention group with the antimicrobial agent. Low incidence of those complications may be the underlying cause. Severe morbidity at pbx is uncommon. Specifically, the rate of infection was very low. PATIENT SUMMARY: Severe complications at prostate biopsy are rare. Among participants, 69.3% had no pain. Fever was rare (1.9% of patients). Voiding issues with catheterization occurred in 3.1%. Most common complications were blood in the semen (47.4%), urine (23.8%), or stool (7.4%). Men with voiding issues or previous infectious complications had a higher risk of infectious complications.", "provenance": [ { "field": "n", "quote": "Return rate was 73.2% (n=732)" }, { "field": "population", "quote": "Transrectal prostate biopsy (pbx) is the most frequent outpatient procedure in the urological field." }, { "field": "intervention", "quote": "Randomization for pbx with the instillation of an antimicrobial lubricant (intervention group, n=385)" }, { "field": "comparator", "quote": "or the standard lubricant (control group, n=347) was performed." }, { "field": "primaryOutcome", "quote": "To evaluate complication rates with or without an antimicrobial lubricant." }, { "field": "result", "quote": "The use of an antimicrobial lubricant did not reduce infection rate. Overall complication rate was very low." }, { "field": "result", "quote": "Most common complications were hematospermia (47.4%), macrohematuria (23.8%), and rectal bleeding (7.4%)." } ] }, { "id": "pmid:29324630", "pmid": "29324630", "doi": "10.1097/PEC.0000000000001388", "nctId": null, "pmcid": null, "title": "Perforated Meckel Diverticulum: A Rare Cause of Acute Abdomen in Children", "firstAuthor": "Talathi", "multipleAuthors": true, "journal": "Pediatr Emerg Care", "year": 2020, "design": "case-series", "n": 1, "nField": "reported", "population": "a patient with acute abdomen in whom the more common causes of acute abdomen were ruled out", "intervention": "exploratory laparoscopy to find the cause", "comparator": "", "primaryOutcome": "identifying the cause of acute abdomen", "result": "a diagnosis of MD was established on exploratory laparoscopy, only after he developed perforation", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single case report, so it cannot show how common or reliable this cause is.", "directness": "indirect", "limitations": "Single patient case report describing a child with acute abdominal pain and perforation, not specifically painless bleeding.", "followUp": "", "plainFinding": "Meckel diverticulum can cause painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/29324630/", "sourceText": "Meckel diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract and the most common cause of gastrointestinal bleeding in children. Although it usually follows the rule of 2's, exceptions to this rule are reported in the literature. Often asymptomatic, MD is commonly an incidental finding during surgical interventions. When symptomatic, the most common presentation of this condition is painless rectal bleeding. A myriad of other nonspecific symptoms are however possible, especially in adults, thus making this diagnosis difficult. Meckel diverticulum has been reported to mimic other abdominal pathologies like appendicitis, inflammatory bowel disease, and pancreatitis to name a few.We report a patient with acute abdomen in whom the more common causes of acute abdomen were ruled out and a diagnosis of MD was established on exploratory laparoscopy, only after he developed perforation. This report emphasizes the need for maintaining a high index of suspicion towards a possibility of a complicated MD in patients presenting with an acute abdomen, once other causes of acute abdomen are ruled out.", "provenance": [ { "field": "population", "quote": "We report a patient with acute abdomen in whom the more common causes of acute abdomen were ruled out" }, { "field": "intervention", "quote": "a diagnosis of MD was established on exploratory laparoscopy" }, { "field": "primaryOutcome", "quote": "This report emphasizes the need for maintaining a high index of suspicion towards a possibility of a complicated MD in patients presenting with an acute abdomen" }, { "field": "result", "quote": "a diagnosis of MD was established on exploratory laparoscopy, only after he developed perforation" }, { "field": "n", "quote": "We report a patient with acute abdomen" } ] }, { "id": "pmid:27554385", "pmid": "27554385", "doi": null, "nctId": null, "pmcid": null, "title": "Hemangioma of the rectum - How misleading can hematochezia be?", "firstAuthor": "Vitor", "multipleAuthors": true, "journal": "Rev Esp Enferm Dig", "year": 2016, "design": "case-series", "n": 1, "nField": "reported", "population": "an 18-year-old male patient that was referred to our gastrenterology department with history of intermittent painless hematochezia since childhood", "intervention": "We adopted a conservative strategy with clinical surveillance and iron supplementation.", "comparator": "After discussion, we considered to perform a sphincter-sparing procedure, namely pull through transection and coloanal anastomosis.", "primaryOutcome": "the patient remains with intermittent rectal bleeding, referring poor quality of life due to his ongoing symptoms", "result": "the patient remains with intermittent rectal bleeding, referring poor quality of life due to his ongoing symptoms", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how common this cause is or how well treatments work.", "directness": "direct", "limitations": "Single case report; no control group; surgical treatment was not performed so its effectiveness could not be assessed in this patient.", "followUp": "", "plainFinding": "Rectal hemangioma caused painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/27554385/", "sourceText": "We present the case of an 18-year-old male patient that was referred to our gastrenterology department with history of intermittent painless hematochezia since childhood. During such instances, he was diagnosed with bowel intussusception, eosinophilic gastroenteritis and inflammatory bowel disease at 4, 6 and 8 years old, respectively. He underwent treatment with 5-aminosalicylic acid for two years, without improvement of symptoms. He was then lost to follow-up until our observation. His physical examination was unremarkable except for digital rectal examination which found a nodular compressible mass by the palpating finger. Blood tests revealed a mild iron deficiency anemia. The colonoscopy showed an extended reddish and bluish multinodular submucosal mass in the rectum, suggesting diffuse cavernous hemangioma of the rectum (DHCR). The Magnetic Resonance Imaging, showed diffuse thickening of the entire rectum extending into the distal sigmoid with the mesorectum revealing multiple serpiginous structures, corresponding to abnormal blood vessels. After discussion, we considered to perform a sphincter-sparing procedure, namely pull through transection and coloanal anastomosis. However, intervention was ruled out by the patient because of his fear of anal incontinence and permanent colostomy. We adopted a conservative strategy with clinical surveillance and iron supplementation. At the present, the patient remains with intermittent rectal bleeding, referring poor quality of life due to his ongoing symptoms. This is a rare case of DHCR. Despite of being a benign disease, the management of DHCR requires a sphincter mucosectomy and pull-through coloanal sleeve anastomosis which has become the first-line procedure. The surgical outcomes are non-expectable in 32% with permanent sphincter lesion or with incomplete DHCR removal. As in this case, the surgeons or patients refusal to perform the intervention is common which represents a challenge to the clinical follow-up.", "provenance": [ { "field": "n", "quote": "We present the case of an 18-year-old male patient" }, { "field": "population", "quote": "an 18-year-old male patient that was referred to our gastrenterology department with history of intermittent painless hematochezia since childhood" }, { "field": "intervention", "quote": "We adopted a conservative strategy with clinical surveillance and iron supplementation." }, { "field": "comparator", "quote": "After discussion, we considered to perform a sphincter-sparing procedure, namely pull through transection and coloanal anastomosis." }, { "field": "primaryOutcome", "quote": "the patient remains with intermittent rectal bleeding, referring poor quality of life due to his ongoing symptoms" }, { "field": "result", "quote": "the patient remains with intermittent rectal bleeding, referring poor quality of life due to his ongoing symptoms" } ] }, { "id": "pmid:27312852", "pmid": "27312852", "doi": "10.1136/bcr-2015-214193", "nctId": null, "pmcid": "PMC4932386", "title": "Rectal adenocarcinoma infiltrating the bulbar urethra and metastasising to the penis", "firstAuthor": "James", "multipleAuthors": true, "journal": "BMJ Case Rep", "year": 2016, "design": "case-series", "n": 1, "nField": "reported", "population": "A man with constipation and rectal bleeding, found to have rectal cancer", "intervention": "Diversion colostomy and chemoradiation", "comparator": "None", "primaryOutcome": "Response of tumour to treatment", "result": "Rectal cancer had spread to the penis and did not respond to chemoradiotherapy", "resultDirection": "no-benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, which cannot show whether treatments work in general.", "directness": "indirect", "limitations": "Single case report with no comparison group; describes advanced cancer with spread, not a general cause of painless rectal bleeding.", "followUp": "", "plainFinding": "Rectal cancer spread to penis.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/27312852/", "sourceText": "Secondary penile tumours from rectal carcinoma is a known clinical entity but can be missed unless carefully evaluated. We report a case of rectal adenocarcinoma with synchronous painless penile nodules. A patient presented with constipation and rectal bleeding. He had an anorectal growth as well as palpable nodules on his penis. Rectal biopsy yielded adenocarcinoma. Imaging revealed direct infiltration of tumour into the bulb of the penis as well as distal shaft lesions. Fine-needle aspiration cytology of the penile nodule showed metastatic adenocarcinoma. Diversion colostomy was performed and the patient referred for chemoradiation. Since he did not have any urinary symptoms, the penile lesions were left unaltered. Repeat imaging after concurrent chemoradiotherapy showed no response. The prognosis was explained and the patient was given palliative clinic care.", "provenance": [ { "field": "n", "quote": "We report a case of rectal adenocarcinoma with synchronous painless penile nodules." }, { "field": "population", "quote": "A patient presented with constipation and rectal bleeding." }, { "field": "intervention", "quote": "Diversion colostomy was performed and the patient referred for chemoradiation." }, { "field": "comparator", "quote": "the penile lesions were left unaltered" }, { "field": "primaryOutcome", "quote": "Repeat imaging after concurrent chemoradiotherapy showed no response." }, { "field": "result", "quote": "Repeat imaging after concurrent chemoradiotherapy showed no response." } ] }, { "id": "pmid:26788380", "pmid": "26788380", "doi": "10.1155/2015/938346", "nctId": null, "pmcid": "PMC4695658", "title": "Not Just Painless Bleeding: Meckel's Diverticulum as a Cause of Small Bowel Obstruction in Children-Two Cases and a Review of the Literature", "firstAuthor": "Itriyeva", "multipleAuthors": true, "journal": "Case Rep Emerg Med", "year": 2015, "design": "case-series", "n": 2, "nField": "reported", "population": "children presenting to the emergency department with bowel problems", "intervention": "not applicable (diagnostic case review)", "comparator": "", "primaryOutcome": "cause of intestinal obstruction symptoms", "result": "two children had intestinal obstruction caused by Meckel's diverticulum, not painless bleeding", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is just two patient cases, not a study designed to measure how well a treatment works", "directness": "indirect", "limitations": "only two cases described, no comparison group, cannot show how common this is", "followUp": "", "plainFinding": "Meckel's diverticulum can cause blockage, not just bleeding", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26788380/", "sourceText": "Physicians are educated with the classical teaching that symptomatic patients with Meckel's diverticulum (MD) most often present with painless rectal bleeding. However, a review of the literature reveals that young patients with MD will most commonly present with signs of intestinal obstruction, an etiology not frequency considered in patients presenting to the emergency department with obstruction. We present two cases of intestinal obstruction diagnosed in our emergency department, with Meckel's diverticulum being the etiology.", "provenance": [ { "field": "population", "quote": "young patients with MD" }, { "field": "intervention", "quote": "We present two cases of intestinal obstruction diagnosed in our emergency department, with Meckel's diverticulum being the etiology." }, { "field": "primaryOutcome", "quote": "Meckel's diverticulum being the etiology" }, { "field": "result", "quote": "young patients with MD will most commonly present with signs of intestinal obstruction" }, { "field": "n", "quote": "We present two cases of intestinal obstruction diagnosed in our emergency department" } ] }, { "id": "pmid:26309351", "pmid": "26309351", "doi": "10.3748/wjg.v21.i31.9245", "nctId": null, "pmcid": "PMC4541377", "title": "Treatment of hemorrhoids: A coloproctologist's view", "firstAuthor": "Lohsiriwat", "multipleAuthors": false, "journal": "World J Gastroenterol", "year": 2015, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids", "intervention": "various hemorrhoid treatments (medication, rubber band ligation, sclerotherapy, surgery)", "comparator": "no single comparator specified", "primaryOutcome": "", "result": "the abstract describes treatment options by severity but does not report a specific outcome measurement or benefit comparison", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is an expert review/editorial describing general treatment practices, not a study testing a specific treatment with measured results.", "directness": "direct", "limitations": "no original data, no outcome measures, no comparison results reported; it is an editorial/review of clinical practice.", "followUp": "", "plainFinding": "Painless bleeding is typical of hemorrhoids.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26309351/", "sourceText": "Hemorrhoids is recognized as one of the most common medical conditions in general population. It is clinically characterized by painless rectal bleeding during defecation with or without prolapsing anal tissue. Generally, hemorrhoids can be divided into two types: internal hemorrhoid and external hemorrhoid. External hemorrhoid usually requires no specific treatment unless it becomes acutely thrombosed or causes patients discomfort. Meanwhile, low-graded internal hemorrhoids can be effectively treated with medication and non-operative measures (such as rubber band ligation and injection sclerotherapy). Surgery is indicated for high-graded internal hemorrhoids, or when non-operative approaches have failed, or complications have occurred. Although excisional hemorrhoidectomy remains the mainstay operation for advanced hemorrhoids and complicated hemorrhoids, several minimally invasive operations (including Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation and stapled hemorrhoidopexy) have been introduced into surgical practices in order to avoid post-hemorrhiodectomy pain. This article deals with some fundamental knowledge and current treatment of hemorrhoids in a view of a coloproctologist - which includes the management of hemorrhoids in complicated situations such as hemorrhoids in pregnancy, hemorrhoids in immunocompromised patients, hemorrhoids in patients with cirrhosis or portal hypertension, hemorrhoids in patients having antithrombotic agents, and acutely thrombosed or strangulated hemorrhoids. Future perspectives in the treatment of hemorrhoids are also discussed.", "provenance": [ { "field": "population", "quote": "Hemorrhoids is recognized as one of the most common medical conditions in general population." }, { "field": "result", "quote": "It is clinically characterized by painless rectal bleeding during defecation with or without prolapsing anal tissue." }, { "field": "intervention", "quote": "low-graded internal hemorrhoids can be effectively treated with medication and non-operative measures (such as rubber band ligation and injection sclerotherapy)" }, { "field": "intervention", "quote": "several minimally invasive operations (including Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation and stapled hemorrhoidopexy) have been introduced into surgical practices" }, { "field": "comparator", "quote": "Surgery is indicated for high-graded internal hemorrhoids, or when non-operative approaches have failed, or complications have occurred." } ] }, { "id": "pmid:25868947", "pmid": "25868947", "doi": "10.1111/ped.12452", "nctId": null, "pmcid": null, "title": "Rare causes of gastrointestinal hemorrhage in infancy", "firstAuthor": "Karakus", "multipleAuthors": true, "journal": "Pediatr Int", "year": 2015, "design": "case-series", "n": null, "nField": "not-reported", "population": "infants with gastrointestinal bleeding", "intervention": "none (diagnostic case description)", "comparator": "", "primaryOutcome": "cause of gastrointestinal bleeding", "result": "describes rare causes of bleeding including heterotopic pancreas and juvenile polyps, which often cause painless rectal bleeding", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a small case report series describing rare conditions, not a study testing a treatment or comparing outcomes.", "directness": "indirect", "limitations": "Case report of rare conditions in infants; no sample size, no comparison group, and no quantitative outcome data given.", "followUp": "", "plainFinding": "Rare bowel conditions can cause painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25868947/", "sourceText": "Gastrointestinal hemorrhage in children is a critical condition that demands quick and effective management. The differential diagnosis of gastrointestinal hemorrhage is wide. Heterotopic pancreas is a rare congenital anomaly and usually discovered incidentally. It is generally asymptomatic, but symptoms may occur when complicated by inflammation, bleeding, obstruction or malign transformation. Heterotopic pancreas may present throughout the gastrointestinal tract, but it is most commonly found in the stomach, duodenum and proximal jejunum. Juvenile polyps are common during childhood and present most often with painless rectal hemorrhage. They remain the most common colonic polyps in children. Colonoscopic polypectomy is the most effective procedure in the treatment of juvenile polyps. In this study, we describe rare causes of gastrointestinal system hemorrhage in infancy and discuss some diagnostic and therapeutic approaches.", "provenance": [ { "field": "population", "quote": "Gastrointestinal hemorrhage in children is a critical condition that demands quick and effective management." }, { "field": "result", "quote": "Juvenile polyps are common during childhood and present most often with painless rectal hemorrhage." }, { "field": "primaryOutcome", "quote": "In this study, we describe rare causes of gastrointestinal system hemorrhage in infancy and discuss some diagnostic and therapeutic approaches." }, { "field": "intervention", "quote": "Colonoscopic polypectomy is the most effective procedure in the treatment of juvenile polyps." } ] }, { "id": "pmid:25419283", "pmid": "25419283", "doi": "10.11604/pamj.2014.18.145.3119", "nctId": null, "pmcid": "PMC4236781", "title": "Direct current electrotherapy for internal haemorrhoids: experience in a tertiary health institution", "firstAuthor": "Olatoke", "multipleAuthors": true, "journal": "Pan Afr Med J", "year": 2014, "design": "case-series", "n": null, "nField": "not-reported", "population": "people with symptomatic grade 1, 2 or 3 internal or mixed hemorrhoids, most commonly presenting with rectal bleeding", "intervention": "direct current electrotherapy applied to the hemorrhoid tissue via a proctoscope", "comparator": "no comparison group; all patients received the same treatment", "primaryOutcome": "whether symptoms (bleeding, prolapse, pain, itching) resolved after treatment", "result": "all treated patients were free of symptoms at a mean follow-up of 16 months, with no complications", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a single-arm case series without a control group, so it cannot show whether the improvement was due to the treatment itself.", "directness": "indirect", "limitations": "no control group, no randomization, and the abstract does not report how many patients were enrolled overall", "followUp": "16 months", "plainFinding": "Symptom-free after electrotherapy treatment", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25419283/", "sourceText": "INTRODUCTION: Haemorrhoids disease is one of the most frequently occurring disabling conditions of the anorectum. We re-present the method, advantages and results of using direct current electrotherapy in the treatment of haemorrhoids. METHODS: Symptomatic grades 1, 2 or 3 internal and mixed haemorroids were treated. Exposure and evaluation was with an operative proctoscope which visualized one-eighth of the anal canal at a time. All diseased segments were treated per visit, indicators of successful treatment were, darkening of the treated segment, immediate shrinking of the haemorrhoid and ceasation of popping sound of gas release at the probe tip. Patients were followed up for two weeks. No bowel preparations, medications, anesthesia nor admission was required. RESULTS: Four hundred and fifty six segments were exposed, 252(55.3%) were diseased. eight patients with either grades 2 or 3 diseases required two treatment visits. The most common symptom was rectal bleeding (94.7%), followed by prolapsed but manually reduced hemorrhoids (68%). Prolapse of tuft of haemorrhoidal tissue with spontaneous return was seen in 59.6%, anal pain in 29.8%, and itching in 3.5%. the median number treated segments per patient was 4. No complication was encountered. All patients treated remained symptom free at a mean duration of follow up of 16 months. CONCLUSION: Direct current electrotherapy is an effective, painless and safe out-patient treatment method for grades 1 to 3 internal and mixed hemorrhoid disease.", "provenance": [ { "field": "population", "quote": "Symptomatic grades 1, 2 or 3 internal and mixed haemorroids were treated" }, { "field": "population", "quote": "The most common symptom was rectal bleeding (94.7%)" }, { "field": "intervention", "quote": "using direct current electrotherapy in the treatment of haemorrhoids" }, { "field": "comparator", "quote": "No bowel preparations, medications, anesthesia nor admission was required." }, { "field": "primaryOutcome", "quote": "indicators of successful treatment were, darkening of the treated segment, immediate shrinking of the haemorrhoid and ceasation of popping sound of gas release at the probe tip" }, { "field": "result", "quote": "All patients treated remained symptom free at a mean duration of follow up of 16 months." }, { "field": "followUp", "quote": "mean duration of follow up of 16 months" } ] }, { "id": "pmid:25366092", "pmid": "25366092", "doi": "10.1007/s00270-014-1017-8", "nctId": null, "pmcid": null, "title": "Emborrhoid: a new concept for the treatment of hemorrhoids with arterial embolization: the first 14 cases", "firstAuthor": "Vidal", "multipleAuthors": true, "journal": "Cardiovasc Intervent Radiol", "year": 2015, "design": "case-series", "n": 14, "nField": "reported", "population": "patients with ongoing rectal bleeding from hemorrhoids", "intervention": "embolization of the hemorrhoid arteries (emborrhoid technique)", "comparator": "none (no comparison group)", "primaryOutcome": "whether bleeding stopped and how safe the procedure was", "result": "72% of patients had bleeding resolve at one month, with no pain or complications in most", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "Only 14 patients were treated with no comparison group, so it can't show the procedure truly works better than other options.", "directness": "direct", "limitations": "small uncontrolled case series; authors state additional studies needed to evaluate efficacy", "followUp": "1 month", "plainFinding": "New procedure stopped bleeding in most patients.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/25366092/", "sourceText": "PURPOSE: The 'emborrhoid' technique consists of the embolization of the hemorrhoidal arteries. The endovascular arterial occlusion is performed using coils placed in the terminal branches of the superior rectal arteries. The emborrhoid technique has been modeled after elective transanal Doppler-guided hemorrhoidal artery ligation which has been shown to be effective in hemorrhoidal disease. We report the first 14 cases of our experience with emborrhoid technique. MATERIALS AND METHODS: Fourteen patients with disabling chronic rectal bleeding were treated using the emborrhoid technique (3 women, 11 men). The stage of the hemorrhoidal disease was II (10 patients), III (3), and IV (1). This treatment was decided by a multidisciplinary team (proctologist, visceral surgeon, and radiologist). Seven patients underwent previous proctological surgery. Ten patients had coagulation disorders (anticoagulants or cirrhosis). Superior rectal arteries were embolized with pushable microcoils (0.018). RESULTS: Technical success of the embolization procedure was 100 %. Clinical success at 1 month was 72 % (10/14). Of the 4 patients who experienced rebleeding, two underwent additional embolization of the posterior rectal arteries with success. No pain or ischemic complications were observed in 13 patients. One patient experienced a temporary painful and edematous, perianal reaction. CONCLUSION: Our case studies suggest that coil embolization of the superior rectal arteries is technically feasible, safe and well tolerated. Additional studies are needed to evaluate the efficacy of this new 'emborrhoid' technique in the management of hemorrhoidal disease.", "provenance": [ { "field": "n", "quote": "Fourteen patients with disabling chronic rectal bleeding were treated using the emborrhoid technique" }, { "field": "population", "quote": "Fourteen patients with disabling chronic rectal bleeding were treated using the emborrhoid technique" }, { "field": "intervention", "quote": "The 'emborrhoid' technique consists of the embolization of the hemorrhoidal arteries." }, { "field": "comparator", "quote": "Fourteen patients with disabling chronic rectal bleeding were treated using the emborrhoid technique" }, { "field": "primaryOutcome", "quote": "Clinical success at 1 month was 72 % (10/14)." }, { "field": "result", "quote": "Clinical success at 1 month was 72 % (10/14)." }, { "field": "result", "quote": "No pain or ischemic complications were observed in 13 patients." } ] }, { "id": "pmid:24829679", "pmid": "24829679", "doi": null, "nctId": null, "pmcid": "PMC3990143", "title": "Lower Gastrointestinal Bleeding due to Non-Steroid Anti-Inflammatory Drug-Induced Colopathy Case Report and Literature Review", "firstAuthor": "Mokhtare", "multipleAuthors": true, "journal": "Middle East J Dig Dis", "year": 2013, "design": "case-series", "n": 1, "nField": "reported", "population": "43-year-old woman taking NSAIDs for low back pain", "intervention": "NSAID use (non-steroidal anti-inflammatory drugs)", "comparator": "none", "primaryOutcome": "rectal bleeding (painless passage of blood in stool)", "result": "NSAID use was linked to colon damage causing painless rectal bleeding; bleeding addressed by stopping the drug", "resultDirection": "harm", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how common or reliable this cause is.", "directness": "direct", "limitations": "Single case report; no control group; causality inferred rather than proven.", "followUp": "", "plainFinding": "NSAID drug caused painless rectal bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24829679/", "sourceText": "The adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs) on the upper gastrointestinal (GI) tract and small intestine are well established. The effect of such therapy on the large intestine, so called NSAID-induced colopathy, is less well described. NSAID-induced colopathy usually involves the right colon due to a higher concentration of the drug at this site, but the rectum may also be involved. NSAIDs possibly damage the normal large intestine, which presents as ulceration, colitis and stricture. Even though several studies found that NSAIDs can cause diverticular bleeding and perforation, flare-up of inflammatory bowel disease ,and play a role as an etiologic factor in lymphocytic colitis. Inflammatory bowel diseases , malignancy and infectious colitis must be ruled out before establishing the diagnosis of NSAID -induced colopathy. Discontinuation of the offending drug is mandatory. Here, we have reported the case of a 43-year-old female, NSAID user due to low back pain, who was admitted to the hospital with painless hematochezia.", "provenance": [ { "field": "n", "quote": "the case of a 43-year-old female" }, { "field": "population", "quote": "a 43-year-old female, NSAID user due to low back pain, who was admitted to the hospital with painless hematochezia" }, { "field": "intervention", "quote": "NSAID user due to low back pain" }, { "field": "primaryOutcome", "quote": "admitted to the hospital with painless hematochezia" }, { "field": "result", "quote": "Discontinuation of the offending drug is mandatory." }, { "field": "comparator", "quote": "Here, we have reported the case of a 43-year-old female, NSAID user due to low back pain, who was admitted to the hospital with painless hematochezia." } ] }, { "id": "pmid:24742083", "pmid": "24742083", "doi": null, "nctId": null, "pmcid": null, "title": "Anorectal conditions: hemorrhoids", "firstAuthor": "Fox", "multipleAuthors": true, "journal": "FP Essent", "year": 2014, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids, especially adults over 50", "intervention": "", "comparator": "", "primaryOutcome": "cause of painless rectal bleeding", "result": "hemorrhoids are the most common cause of bright red, painless rectal bleeding during bowel movements, but colon cancer must be ruled out with colonoscopy in those at risk", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a general review article summarizing known facts, not a study testing a treatment or measuring outcomes.", "directness": "direct", "limitations": "no original data, numbers, or control group; it is a descriptive overview rather than a research study.", "followUp": "", "plainFinding": "Hemorrhoids often cause painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24742083/", "sourceText": "Hemorrhoids are engorged fibrovascular cushions lining the anal canal. Constipation, increased intra-abdominal pressure, and prolonged straining predispose to hemorrhoids. Approximately 1 in 20 Americans and almost one-half of individuals older than 50 years experience symptomatic hemorrhoids. Bright red, painless rectal bleeding during defecation is the most common presentation. Even if hemorrhoids are seen on examination, patients with rectal bleeding who are at risk of colorectal cancer (eg, adults older than 50 years) should still undergo colonoscopy to exclude cancer as the etiology. Nonsurgical treatment for nonthrombosed hemorrhoids includes increased fiber intake, sitz baths, and drugs. If nonsurgical management is unsuccessful, rubber band ligation is the most effective office-based procedure for grades I, II, and III hemorrhoids. Surgical hemorrhoidectomy is indicated after failure of nonsurgical management and office-based procedures and also as initial management for grades III and IV hemorrhoids. Several different procedures can be used. For acutely thrombosed external hemorrhoids, excision and evacuation of the clot, ideally within 72 hours of symptom onset, is the optimal management. Prolapsed and strangulated hemorrhoids are best managed with stool softeners, analgesics, rest, warm soaks, and ice packs until recovery; residual hemorrhoids are banded or excised later.", "provenance": [ { "field": "population", "quote": "Approximately 1 in 20 Americans and almost one-half of individuals older than 50 years experience symptomatic hemorrhoids." }, { "field": "result", "quote": "Bright red, painless rectal bleeding during defecation is the most common presentation." }, { "field": "result", "quote": "Even if hemorrhoids are seen on examination, patients with rectal bleeding who are at risk of colorectal cancer (eg, adults older than 50 years) should still undergo colonoscopy to exclude cancer as the etiology." }, { "field": "primaryOutcome", "quote": "Bright red, painless rectal bleeding during defecation is the most common presentation." } ] }, { "id": "pmid:26157856", "pmid": "26157856", "doi": "10.14309/crj.2014.32", "nctId": null, "pmcid": "PMC4435309", "title": "Hematochezia Associated with Sevalamer-Induced Mucosal Injury", "firstAuthor": "Chintamaneni", "multipleAuthors": true, "journal": "ACG Case Rep J", "year": 2014, "design": "case-series", "n": 1, "nField": "reported", "population": "61-year-old woman with end-stage kidney disease on anticoagulation", "intervention": "sevelamer (phosphate binder medication)", "comparator": "none", "primaryOutcome": "cause of painless rectal bleeding", "result": "a colon ulcer caused by sevelamer crystals embedded in the colon lining led to painless bleeding", "resultDirection": "harm", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common this cause is or apply broadly.", "directness": "direct", "limitations": "only one patient described; no comparison group; rare and specific cause.", "followUp": "", "plainFinding": "Bleeding from a drug-caused colon ulcer.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26157856/", "sourceText": "We present a case of a 61-year-old woman with end-stage renal disease (ESRD) who developed painless hematochezia following initiation of anticoagulation. Work-up revealed a large ulceration in the sigmoid colon, and histologic images revealed sevelamer crystals embedded in the colonic mucosa, consistent with sevelamer crystal-mediated injury. This is a novel cause of gastrointestinal hemorrhage that has not previously been described in the literature. Physicians should be aware of the potential for sevelamer-induced injury.", "provenance": [ { "field": "population", "quote": "a 61-year-old woman with end-stage renal disease (ESRD) who developed painless hematochezia following initiation of anticoagulation" }, { "field": "intervention", "quote": "sevelamer crystals embedded in the colonic mucosa, consistent with sevelamer crystal-mediated injury" }, { "field": "result", "quote": "Work-up revealed a large ulceration in the sigmoid colon, and histologic images revealed sevelamer crystals embedded in the colonic mucosa, consistent with sevelamer crystal-mediated injury" }, { "field": "primaryOutcome", "quote": "painless hematochezia" }, { "field": "n", "quote": "a 61-year-old woman" }, { "field": "comparator", "quote": "This is a novel cause of gastrointestinal hemorrhage that has not previously been described in the literature." } ] }, { "id": "pmid:24518735", "pmid": "24518735", "doi": "10.4103/0973-1482.126483", "nctId": null, "pmcid": null, "title": "Combined adenocarcinoma-carcinoid tumor of transverse colon", "firstAuthor": "Bhattacharjee", "multipleAuthors": true, "journal": "J Cancer Res Ther", "year": 2013, "design": "case-series", "n": 1, "nField": "reported", "population": "a 65-year-old man with painless rectal bleeding, abdominal cramps, diarrhea, and an abdominal mass", "intervention": "surgical removal of the colon tumor and adjacent bowel", "comparator": "none", "primaryOutcome": "diagnosis and outcome after surgery for the tumor", "result": "found to have a rare mixed tumor (adenocarcinoma and carcinoid) of the colon; after surgery and chemotherapy, no recurrence at one year", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common this cause is or how well treatment works in general", "directness": "direct", "limitations": "single case, no comparison group, short follow-up", "followUp": "a year", "plainFinding": "Rare colon tumor found as cause", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24518735/", "sourceText": "A 65-year-old male presented with painless hematochezia associated with episodic cramps in upper abdomen, watery diarrhea, and a slowly growing mass in upper abdomen. Examination revealed a firm 6 x 5 cm, intra-abdominal, epigastric mass. Colonoscopy up to 90 cm showed a stenosing, ulcero-proliferative lesion in the transverse colon. No synchronous lesion was detected. Biopsy revealed mucin secreting adenocarcinoma. Exploration showed the growth involving the transverse colon proximal to the splenic flexure with a part of ileum, approximately three feet proximal to ileo-caecal junction, adherent to it. No significant mesenteric lymph node enlargement was evident. The patient underwent resection of the growth along with the segment of adherent ileum. Continuity was re-established by a colo-colic and ileo-ileal anastomosis respectively. Patient received adjuvant chemotherapy. Post-operative histopathology demonstrated a composite histological pattern with an admixture of carcinoid tumor and adenocarcinoma, invasion of ileal serosa and adenocarcinomatous deposits in mesocolic lymph nodes, the tumor staging being (T4, N0, M0/Stage II) for carcinoid and (T4, N1, M0/Stage III) for adenocarcinoma. Patient was followed-up for a year and was doing well without any evidence of recurrence.", "provenance": [ { "field": "population", "quote": "A 65-year-old male presented with painless hematochezia associated with episodic cramps in upper abdomen, watery diarrhea, and a slowly growing mass in upper abdomen." }, { "field": "n", "quote": "A 65-year-old male presented" }, { "field": "intervention", "quote": "The patient underwent resection of the growth along with the segment of adherent ileum." }, { "field": "comparator", "quote": "Continuity was re-established by a colo-colic and ileo-ileal anastomosis respectively." }, { "field": "primaryOutcome", "quote": "Post-operative histopathology demonstrated a composite histological pattern with an admixture of carcinoid tumor and adenocarcinoma" }, { "field": "result", "quote": "Patient was followed-up for a year and was doing well without any evidence of recurrence." }, { "field": "followUp", "quote": "followed-up for a year" } ] }, { "id": "pmid:23798019", "pmid": "23798019", "doi": "10.1024/0040-5930/a000421", "nctId": null, "pmcid": null, "title": "[Evidence-based treatment of hemorrhoidal disease]", "firstAuthor": "Grandel", "multipleAuthors": true, "journal": "Ther Umsch", "year": 2013, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoidal disease (hemorrhoids)", "intervention": "various operative and non-operative treatments for hemorrhoids", "comparator": "", "primaryOutcome": "not clearly stated as a measured outcome", "result": "the abstract notes painless rectal bleeding is a common early symptom of hemorrhoids and offers general treatment guidance, without presenting trial results", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a general review summarizing expert experience and existing knowledge rather than presenting new study data or outcomes.", "directness": "indirect", "limitations": "the abstract does not describe a specific study design, sample, or measured results, so it cannot establish cause or treatment effect by itself.", "followUp": "", "plainFinding": "Painless bleeding often from hemorrhoids.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23798019/", "sourceText": "Hemorrhoidal disease represents a prevalent benign condition of the lower gastrointestinal tract. As a common and early symptom of hemorrhoids, patients present with painless rectal bleeding during or after defecation. For the treatment of hemorrhoidal disease, a large variety of operative and non-operative therapeutic options exists. In the present article, the authors aim to provide guidance for stage-directed therapy of hemorrhoidal disease based on up-to-date knowledge and the authors' own clinical experience.", "provenance": [ { "field": "population", "quote": "Hemorrhoidal disease represents a prevalent benign condition of the lower gastrointestinal tract." }, { "field": "result", "quote": "As a common and early symptom of hemorrhoids, patients present with painless rectal bleeding during or after defecation." }, { "field": "intervention", "quote": "a large variety of operative and non-operative therapeutic options exists" }, { "field": "primaryOutcome", "quote": "the authors aim to provide guidance for stage-directed therapy of hemorrhoidal disease based on up-to-date knowledge and the authors' own clinical experience." } ] }, { "id": "pmid:23769256", "pmid": "23769256", "doi": null, "nctId": null, "pmcid": null, "title": "[Rectal cancer and Trousseau syndrome. Case report]", "firstAuthor": "Sierra-Montenegro", "multipleAuthors": true, "journal": "Cir Cir", "year": 2013, "design": "case-series", "n": 1, "nField": "reported", "population": "40-year-old woman with painless rectal bleeding", "intervention": "none (observational case report)", "comparator": "", "primaryOutcome": "diagnosis and clinical course after rectal cancer surgery", "result": "painless bleeding was caused by a rectal tumor (adenocarcinoma); patient later developed Trousseau syndrome with blood clots and died from multi-organ failure after surgery", "resultDirection": "harm", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show what usually causes painless bleeding or how treatment works.", "directness": "direct", "limitations": "only one patient described; no comparison group; outcome reflects a rare and severe complication (Trousseau syndrome), not the usual course of rectal cancer.", "followUp": "", "plainFinding": "Painless bleeding was from rectal cancer.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23769256/", "sourceText": "BACKGROUND: The Trousseau syndrome, first described in 1865, is the relationship of venous thromboembolisms and cancer. We present a case with rectal cancer and Trousseau syndrome. CLINICAL CASE: Female 40 years old, went to the Coloproctology Service for painless bleeding. A computed tomography report showed a tumor of 5 by 6 cm up 5 cm from the anal margin. Ultra-low anterior resection with colonic reservoir and loop ileostomy surgery was performed. The pathology report showed a semidiferenciate adenocarcinoma of the rectum and we established the stage as T3N0M0. Within 72 hours of her operation, she experienced sudden hypotension and painful abdominal distention. A second surgery was done finding necrosis of the colon from the splenic angle until the colonic reservoir with thrombi in the left colic artery, ischemic signs of bilateral fallopian tubes, ovaries, uterus, pelvic floor and the small intestine, 40 cm before ileostomy and ileon. Left hemicolectomy and colostomy was done. She was taken to intensive care where continuous administration of heparin was given; she died within 5 days because of multiorgan failure. CONCLUSIONS: The mechanism for this syndrome was unknown but there are several hypotheses, suggesting that hematological cancer patients are at an increased risk of deep vein thrombosis. Pancreatic cancer is the most common presentation with this syndrome (in 50% of cases). We suggested continuing with the standards of prevention of thromboembolism.", "provenance": [ { "field": "population", "quote": "Female 40 years old, went to the Coloproctology Service for painless bleeding." }, { "field": "intervention", "quote": "Ultra-low anterior resection with colonic reservoir and loop ileostomy surgery was performed." }, { "field": "primaryOutcome", "quote": "A computed tomography report showed a tumor of 5 by 6 cm up 5 cm from the anal margin." }, { "field": "result", "quote": "The pathology report showed a semidiferenciate adenocarcinoma of the rectum" }, { "field": "result", "quote": "she died within 5 days because of multiorgan failure" }, { "field": "n", "quote": "Female 40 years old" } ] }, { "id": "pmid:22574529", "pmid": "22574529", "doi": null, "nctId": null, "pmcid": null, "title": "Acute hemorrhagic rectal ulcer syndrome: the first case series from Thailand", "firstAuthor": "Maneerattanaporn", "multipleAuthors": true, "journal": "J Med Assoc Thai", "year": 2012, "design": "case-series", "n": 9, "nField": "reported", "population": "elderly hospitalized patients with multiple other illnesses who had painless rectal bleeding", "intervention": "none (descriptive review of colonoscopy and biopsy findings)", "comparator": "none", "primaryOutcome": "the endoscopic and tissue characteristics of the rectal ulcers causing bleeding", "result": "the ulcers were multiple, round or oval, located just above the dentate line, with surface damage and signs of recent bleeding confined to the lining of the rectum, and no infectious organisms were found", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a small descriptive case series of only nine patients with no comparison group, so it cannot show whether any treatment helps.", "directness": "direct", "limitations": "Only nine cases from one hospital, purely descriptive, no treatment or outcome comparison reported.", "followUp": "", "plainFinding": "Painless bleeding from ulcers near anus.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/22574529/", "sourceText": "The term \"Acute hemorrhagic rectal ulcer syndrome (AHRUS)\" has been denoted as a pathological entity that consists of lower gastrointestinal bleeding with unique clinical features. The common setting can be found in elderly patients who were hospitalized with multiple comorbidities. The typical location is around the dentate line. The predominant feature of these ulcers is profuse and painless rectal bleeding. Currently, this condition has not been established worldwide and it has never been reported in Thailand. The authors reported nine cases of AHRUS. These cases were reviewed from the records of endoscopic procedures which were performed at Siriraj Endoscopy Center between September-December 2006. All underwent complete colonoscopy to evaluate endoscopic appearances. Histopathologic findings were thoroughly reviewed. The characteristics of the ulcers are multiple, round or oval shape located just above the dentate line, with/without evidence of bleeding stigmata. Histopathologic features included superficial necrosis, erosions with acute inflammatory cell infiltration and evidence of recent hemorrhage, all of which were confined to the mucosal layer. No organisms were discovered from the lesions. In conclusion, this is the first review of AHRUS which is an uncommon cause of hematochezia in Thailand. Although this clinical entity is not well established in Western countries, the rising incidence of AHRUS in Asia warrants further investigation into its pathogenesis, treatment and prevention.", "provenance": [ { "field": "n", "quote": "The authors reported nine cases of AHRUS." }, { "field": "population", "quote": "The common setting can be found in elderly patients who were hospitalized with multiple comorbidities." }, { "field": "population", "quote": "The predominant feature of these ulcers is profuse and painless rectal bleeding." }, { "field": "intervention", "quote": "All underwent complete colonoscopy to evaluate endoscopic appearances." }, { "field": "primaryOutcome", "quote": "Histopathologic findings were thoroughly reviewed." }, { "field": "result", "quote": "The characteristics of the ulcers are multiple, round or oval shape located just above the dentate line, with/without evidence of bleeding stigmata." }, { "field": "result", "quote": "Histopathologic features included superficial necrosis, erosions with acute inflammatory cell infiltration and evidence of recent hemorrhage, all of which were confined to the mucosal layer." }, { "field": "result", "quote": "No organisms were discovered from the lesions." }, { "field": "comparator", "quote": "These cases were reviewed from the records of endoscopic procedures which were performed at Siriraj Endoscopy Center between September-December 2006." } ] }, { "id": "pmid:21766771", "pmid": "21766771", "doi": null, "nctId": null, "pmcid": null, "title": "Hemorrhoids", "firstAuthor": "Mounsey", "multipleAuthors": true, "journal": "Am Fam Physician", "year": 2011, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoids, including those with painless rectal bleeding", "intervention": "various hemorrhoid treatments including stool softeners, rubber band ligation, excisional hemorrhoidectomy, and stapled hemorrhoidopexy", "comparator": "different treatment options compared with each other", "primaryOutcome": "symptom relief, bleeding, pain, and recurrence after treatment", "result": "internal hemorrhoids typically cause painless bleeding or prolapse, and treatments vary in pain, recovery, and recurrence rates", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a general review describing typical hemorrhoid symptoms and treatments, not a study testing one treatment's effect with data to judge reliability", "directness": "direct", "limitations": "no study design, sample size, or original data are given; it summarizes general clinical knowledge rather than reporting a specific trial's results", "followUp": "", "plainFinding": "Painless bleeding often just means hemorrhoids.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/21766771/", "sourceText": "Most patients with hemorrhoids experience only mild symptoms that can be treated with nonprescription topical preparations. Patients usually seek treatment when symptoms increase. Internal hemorrhoids typically present with prolapse or painless rectal bleeding. External hemorrhoids also bleed and can cause acute pain if thrombosed. Medical therapy should be initiated with stool softeners plus local therapy to relieve swelling and symptoms. If medical therapy is inadequate, surgical intervention is warranted. Rubber band ligation is the treatment of choice for grades 1 and 2 hemorrhoids. Rubber band ligation, excisional hemorrhoidectomy, or stapled hemorrhoidopexy can be performed in patients with grade 3 hemorrhoids. Rubber band ligation causes less postoperative pain and fewer complications than excisional hemorrhoidectomy and stapled hemorrhoidopexy, but has a higher recurrence rate. Excisional hemorrhoidectomy or stapled hemorrhoidopexy is recommended for treatment of grade 4 hemorrhoids. Stapled hemorrhoidopexy has a faster postoperative recovery, but a higher recurrence rate. Postoperative pain from excisional hemorrhoidectomy can be treated with nonsteroidal anti-inflammatory drugs, narcotics, fiber supplements, and topical antispasmodics. Thrombosed external hemorrhoids can be treated conservatively or excised.", "provenance": [ { "field": "population", "quote": "Internal hemorrhoids typically present with prolapse or painless rectal bleeding." }, { "field": "intervention", "quote": "Medical therapy should be initiated with stool softeners plus local therapy to relieve swelling and symptoms." }, { "field": "intervention", "quote": "Rubber band ligation is the treatment of choice for grades 1 and 2 hemorrhoids." }, { "field": "comparator", "quote": "Rubber band ligation causes less postoperative pain and fewer complications than excisional hemorrhoidectomy and stapled hemorrhoidopexy, but has a higher recurrence rate." }, { "field": "primaryOutcome", "quote": "Rubber band ligation causes less postoperative pain and fewer complications than excisional hemorrhoidectomy and stapled hemorrhoidopexy, but has a higher recurrence rate." }, { "field": "result", "quote": "Internal hemorrhoids typically present with prolapse or painless rectal bleeding." } ] }, { "id": "pmid:21471763", "pmid": "21471763", "doi": "10.1007/DCR.0b013e3182092e51", "nctId": null, "pmcid": null, "title": "Long-term clinical results of double-pursestring stapled hemorrhoidopexy in a selected group of patients for the treatment of chronic hemorrhoids", "firstAuthor": "Arroyo", "multipleAuthors": true, "journal": "Dis Colon Rectum", "year": 2011, "design": "case-series", "n": 200, "nField": "reported", "population": "patients with long-standing (chronic) third-degree hemorrhoids", "intervention": "double-pursestring stapled hemorrhoidopexy surgery for hemorrhoids", "comparator": "no separate comparison group; same patients compared before and after surgery", "primaryOutcome": "long-term clinical and manometric (anal pressure) results after surgery, including bleeding, pain, and recurrence", "result": "At a median follow-up of about 9 years, 2% of patients reported daily rectal bleeding, 7% had recurrence with prolapse, and anal pressure measurements were unchanged from before surgery", "resultDirection": "mixed", "quality": "low", "qualityWhy": "This is a single-arm follow-up of one surgery type with no untreated or alternative-treatment comparison group, so it cannot show whether the surgery itself caused the good or bad outcomes.", "directness": "indirect", "limitations": "No control group, patients were a 'selected group' treated by expert surgeons, which limits how well results generalize.", "followUp": "Median follow-up was 110 months", "plainFinding": "Low bleeding after hemorrhoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/21471763/", "sourceText": "BACKGROUND AND OBJECTIVE: The aim of this prospective controlled trial was to evaluate the long-term clinical and manometric results of stapled hemorrhoidopexy performed by expert surgeons in a selected group of patients for the treatment of chronic hemorrhoids. SETTINGS: This study took place in the outpatient clinic and at the Day Surgery Unit attached to the University Hospital of Elche. PATIENTS: From March 2003 to May 2005, 200 consecutive patients with third-degree hemorrhoids and treated with double-pursestring stapled hemorrhoidopexy with a PPH33-03 stapler were included in the study. MAIN OUTCOME MEASURES: Demographic, manometric, and clinical features were analyzed, as well as the variables related to surgery, postoperative course, and follow-up. Manometry was repeated at the 6-month, 1-year, and 5-year follow-up. RESULTS: Median follow-up was 110 months. Four patients (2%) reported daily rectal bleeding. One patient with active rectal bleeding was taken for reoperation within the first 12 postoperative hours. Seventy percent of patients reported pain ≤ 2 on the first postoperative day, 85% on the fourth postoperative day, and 95% on the seventh postoperative day. Pain was measured with a linear analog scale from 0 to 10 (0 = no pain; 10 = unbearable pain). Seventeen patients (8.5%) reported tenesmus during the first week. Eight patients (4%) reported persistent pain: in 5 patients, the pain resolved within the next 6 months; 2 patients presented with anal fissure; and 1 patient required the removal of the staples. Two patients (1%) reported residual soiling at the 5-year revision. Fourteen patients (7%) experienced recurrence with symptomatic prolapse. Six (3%) underwent further surgery: stapled hemorrhoidopexy was indicated again in 2 patients, and 4 patients underwent a Milligan-Morgan open hemorrhoidectomy, because they did not have a uniform prolapse. Six patients required treatment with rubber band ligation. There were no statistically significant differences between preoperative and postoperative manometric values. CONCLUSIONS: The new PPH33-03 stapler, the learning process of the modified surgical procedure, and the correct selection of patients will overcome the main objections to stapled hemorrhoidopexy.", "provenance": [ { "field": "population", "quote": "200 consecutive patients with third-degree hemorrhoids" }, { "field": "intervention", "quote": "double-pursestring stapled hemorrhoidopexy with a PPH33-03 stapler" }, { "field": "comparator", "quote": "Manometry was repeated at the 6-month, 1-year, and 5-year follow-up." }, { "field": "primaryOutcome", "quote": "evaluate the long-term clinical and manometric results of stapled hemorrhoidopexy" }, { "field": "result", "quote": "Four patients (2%) reported daily rectal bleeding." }, { "field": "result", "quote": "Fourteen patients (7%) experienced recurrence with symptomatic prolapse." }, { "field": "result", "quote": "There were no statistically significant differences between preoperative and postoperative manometric values." }, { "field": "n", "quote": "200 consecutive patients with third-degree hemorrhoids" }, { "field": "followUp", "quote": "Median follow-up was 110 months" } ] }, { "id": "pmid:20642975", "pmid": "20642975", "doi": null, "nctId": null, "pmcid": null, "title": "Adult ischemic necrotizing enterocolitis", "firstAuthor": "Mitchell", "multipleAuthors": true, "journal": "J Coll Physicians Surg Pak", "year": 2010, "design": "case-series", "n": 1, "nField": "reported", "population": "a 66-year-old man with a heart attack and painless rectal bleeding", "intervention": "none (observation of the natural course of illness)", "comparator": "", "primaryOutcome": "cause of the rectal bleeding and outcome", "result": "bowel tissue death from blocked blood vessels, found after death, causing bowel perforation; patient died 5 days after admission", "resultDirection": "harm", "quality": "very-low", "qualityWhy": "this is a single patient's case, so it cannot show how common this cause is or how it usually turns out.", "directness": "direct", "limitations": "only one patient described; diagnosis made only after death; extensive tests during life did not find the cause.", "followUp": "5 days", "plainFinding": "Bowel tissue death from blocked blood flow.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20642975/", "sourceText": "A 66-year-old male presented with posterior myocardial infarction and painless rectal bleeding. He was treated for acute coronary event but despite extensive investigations the cause of his lower gastrointestinal bleeding remained elusive. Patient died 5 days after admission. Postmortem examination showed evidence of severe atherosclerosis and thrombosis in branches of abdominal aorta leading to bowel ischemia with multiple perforations and necrosis. The findings are consistent with the diagnosis of necrotizing enterocolitis (NEC). Main factors responsible for pathogenesis of NEC are bowel ischemia and bacterial infection. It can be classified into 3 stages according to the level of severity. Treatment ranges from mainly supportive in the initial phase to surgery in severe cases.", "provenance": [ { "field": "n", "quote": "A 66-year-old male presented with posterior myocardial infarction and painless rectal bleeding." }, { "field": "population", "quote": "A 66-year-old male presented with posterior myocardial infarction and painless rectal bleeding." }, { "field": "primaryOutcome", "quote": "despite extensive investigations the cause of his lower gastrointestinal bleeding remained elusive" }, { "field": "intervention", "quote": "He was treated for acute coronary event but despite extensive investigations the cause of his lower gastrointestinal bleeding remained elusive." }, { "field": "result", "quote": "Postmortem examination showed evidence of severe atherosclerosis and thrombosis in branches of abdominal aorta leading to bowel ischemia with multiple perforations and necrosis." }, { "field": "followUp", "quote": "Patient died 5 days after admission." } ] }, { "id": "pmid:20442525", "pmid": "20442525", "doi": null, "nctId": null, "pmcid": null, "title": "Periampullary Dieulafoy's lesion: an unusual cause of gastrointestinal bleeding", "firstAuthor": "Rana", "multipleAuthors": true, "journal": "JOP", "year": 2010, "design": "case-series", "n": 1, "nField": "reported", "population": "a 52-year-old woman with intermittent painless rectal/GI bleeding", "intervention": "endoscopic evaluation and adrenaline injection, followed by surgery", "comparator": "none", "primaryOutcome": "finding and stopping the source of bleeding", "result": "a rare bleeding lesion near the bile duct opening was found and treated, with surgery ultimately needed", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common this cause is or how well treatments generally work", "directness": "direct", "limitations": "only one patient; initial tests missed the lesion; bleeding recurred despite initial treatment", "followUp": "", "plainFinding": "Rare lesion found causing painless bleeding", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20442525/", "sourceText": "CONTEXT: Dieulafoy's lesion is an unusual cause of gastrointestinal bleeding with the most common location being the stomach. A periampullary location is rare for a bleeding Dieulafoy's lesion. CASE REPORT: We present the case of a 52-year-old female who presented with intermittent painless melena. Her upper gastrointestinal endoscopy and colonoscopy were normal. She was a diagnostic challenge as no definite lesion could be identified on capsule endoscopy. However, as there was presence of fresh blood in the proximal jejunum, a push enteroscopy was performed which revealed the presence of fresh blood in the duodenum and proximal jejunum. But no bleeding lesion could be identified. A side view endoscopy was performed which revealed a bleeding periampullary Dieulafoy's lesion. Immediate hemostasis was achieved with an injection of adrenalin. Other episodes of bleeding occurred and the patient was finally treated surgically. CONCLUSION: A periampullary Dieulafoy's lesion presenting with obscure gastrointestinal bleed is a diagnostic challenge and can be missed on capsule endoscopy.", "provenance": [ { "field": "population", "quote": "a 52-year-old female who presented with intermittent painless melena" }, { "field": "intervention", "quote": "A side view endoscopy was performed which revealed a bleeding periampullary Dieulafoy's lesion. Immediate hemostasis was achieved with an injection of adrenalin." }, { "field": "comparator", "quote": "Her upper gastrointestinal endoscopy and colonoscopy were normal." }, { "field": "primaryOutcome", "quote": "as there was presence of fresh blood in the proximal jejunum, a push enteroscopy was performed which revealed the presence of fresh blood in the duodenum and proximal jejunum. But no bleeding lesion could be identified." }, { "field": "result", "quote": "Other episodes of bleeding occurred and the patient was finally treated surgically." }, { "field": "n", "quote": "a 52-year-old female" } ] }, { "id": "pmid:20076822", "pmid": "20076822", "doi": null, "nctId": null, "pmcid": null, "title": "Multiple synchronous granular cell tumors involving the colon, appendix and mesentery: a case report and review of the literature", "firstAuthor": "Saleh", "multipleAuthors": true, "journal": "J Gastrointestin Liver Dis", "year": 2009, "design": "case-series", "n": 1, "nField": "reported", "population": "a 62-year-old woman with a colon mass found during screening", "intervention": "none (diagnostic workup and surgical removal of the mass)", "comparator": "", "primaryOutcome": "whether the growths were cancer or a benign tumor", "result": "the multiple growths in the colon, appendix and mesentery were all benign granular cell tumors, not cancer", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show what causes bleeding in general or how common this is.", "directness": "indirect", "limitations": "Only one patient is described, so the findings may not apply broadly; it does not establish a general cause of painless rectal bleeding.", "followUp": "", "plainFinding": "Rare benign tumor, not cancer.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20076822/", "sourceText": "A granular cell tumor (GCT) is typically a benign neural tumor of Schwann cell origin that occurs in the 4th to 6th decade of life usually as a solitary painless nodule in the dermis or subcutis. It can also be found in internal organs including the larynx, bronchus and gastrointestinal (GI) tract. Within the GI tract, it is most common in the esophagus followed by colon. Colonic GCT is mostly found incidentally during colonoscopy or surgical resection as a solitary submucosal sessile nodule, although, some may cause rectal bleeding. In this report, we describe a case of a 62 year-old woman who was found to have submucosal rectosigmoid mass at screening sigmoidoscopy. Full colonoscopy and CT-scan studies revealed multiple GCTs of the colon, appendix and the mesentery, raising the suspicion of malignant metastatic disease. However, surgical resection of all the masses in an exploratory laporatomy proved them to be benign GCTs. This case emphasizes the need to consider GCTs of the GI tract when multiple asymptomatic lesions are found incidentally in the colon before any aggressive surgical intervention is undertaken. It is also the first case of GCT involving the mesentery. A literature review of GCT of the GI tract is also provided.", "provenance": [ { "field": "n", "quote": "a 62 year-old woman" }, { "field": "population", "quote": "a 62 year-old woman who was found to have submucosal rectosigmoid mass at screening sigmoidoscopy" }, { "field": "intervention", "quote": "surgical resection of all the masses in an exploratory laporatomy" }, { "field": "primaryOutcome", "quote": "raising the suspicion of malignant metastatic disease" }, { "field": "result", "quote": "surgical resection of all the masses in an exploratory laporatomy proved them to be benign GCTs" } ] }, { "id": "pmid:19873964", "pmid": "19873964", "doi": null, "nctId": null, "pmcid": null, "title": "Diverticular bleeding", "firstAuthor": "Wilkins", "multipleAuthors": true, "journal": "Am Fam Physician", "year": 2009, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with diverticular disease who have rectal bleeding", "intervention": "diagnostic and treatment approach for diverticular bleeding (colonoscopy, embolization, vasopressin, surgery)", "comparator": "not applicable", "primaryOutcome": "resolution of bleeding", "result": "bleeding stops on its own in most patients; various procedures can stop ongoing bleeding", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a general review article describing typical management, not a study testing whether a treatment works.", "directness": "direct", "limitations": "This is a review summarizing general knowledge, not original research with its own patient group or control comparison.", "followUp": "", "plainFinding": "Painless bleeding from diverticula usually stops by itself.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/19873964/", "sourceText": "Diverticular bleeding is a common cause of lower gastrointestinal hemorrhage. Patients typically present with massive and painless rectal hemorrhage. If bleeding is severe, initial resuscitative measures should include airway maintenance and oxygen supplementation, followed by measurement of hemoglobin and hematocrit levels, and blood typing and crossmatching. Patients may need intravenous fluid resuscitation with normal saline or lactated Ringer's solution, followed by transfusion of packed red blood cells in the event of ongoing bleeding. Diverticular hemorrhage resolves spontaneously in approximately 80 percent of patients. If there is severe bleeding or significant comorbidities, patients should be admitted to the intensive care unit. The recommended initial diagnostic test is colonoscopy, performed within 12 to 48 hours of presentation and after a rapid bowel preparation with polyethylene glycol solutions. If the bleeding source is identified by colonoscopy, endoscopic therapeutic maneuvers can be performed. These may include injection with epinephrine or electrocautery therapy. If the bleeding source is not identified, radionuclide imaging (i.e., technetium-99m-tagged red blood cell scan) should be performed, usually followed by arteriography. For ongoing diverticular hemorrhage, other therapeutic modalities such as selective embolization, intra-arterial vasopressin infusion, or surgery, should be considered.", "provenance": [ { "field": "population", "quote": "Patients typically present with massive and painless rectal hemorrhage." }, { "field": "intervention", "quote": "The recommended initial diagnostic test is colonoscopy" }, { "field": "comparator", "quote": "If the bleeding source is not identified, radionuclide imaging (i.e., technetium-99m-tagged red blood cell scan) should be performed, usually followed by arteriography." }, { "field": "primaryOutcome", "quote": "Diverticular hemorrhage resolves spontaneously in approximately 80 percent of patients." }, { "field": "result", "quote": "Diverticular hemorrhage resolves spontaneously in approximately 80 percent of patients." } ] }, { "id": "pmid:19366548", "pmid": "19366548", "doi": null, "nctId": null, "pmcid": "PMC3015905", "title": "Ileocecal valve lipoma with refractory hemorrhage", "firstAuthor": "Dultz", "multipleAuthors": true, "journal": "JSLS", "year": 2009, "design": "case-series", "n": null, "nField": "not-reported", "population": "elderly man with painless rectal bleeding", "intervention": "surgical removal of the mass (laparoscopic right hemicolectomy)", "comparator": "none", "primaryOutcome": "identifying cause of bleeding and stopping it", "result": "bleeding was caused by an ulcerated lipoma at the ileocecal valve, successfully treated with surgical removal", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common this cause is or how well treatment works in general", "directness": "direct", "limitations": "only one patient described; no comparison group; findings may not generalize", "followUp": "", "plainFinding": "", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/19366548/", "sourceText": "BACKGROUND: Lipomas are the most common benign mesenchymal tumors of the gastrointestinal tract, with the colon being the most prevalent site. Intestinal lipomas are usually asymptomatic. Tumors >2 cm in diameter may occasionally cause nonspecific symptoms, including change in bowel habits, abdominal pain, or rectal bleeding, but with resection the prognosis is excellent. Herein, we describe the case of an elderly male who presented with painless hematochezia. METHODS: Both colonoscopy and computed tomography of the abdomen and pelvis confirmed the presence of a mass near the ileocecal valve. Because of continuing bleeding, the patient required laparoscopic-assisted right hemicolectomy to resect the mass. RESULTS: Both gross and microscopic pathology were consistent with lipoma at the ileocecal valve. CONCLUSION: Previous cases of ileocecal valve lipomas have been reported in the English literature, with the majority presenting as intussusception or volvulus. We present a rare case of an ulcerated ileocecal valve lipoma presenting as lower gastrointestinal bleeding that was treated successfully with laparoscopic resection.", "provenance": [ { "field": "population", "quote": "an elderly male who presented with painless hematochezia" }, { "field": "intervention", "quote": "laparoscopic-assisted right hemicolectomy to resect the mass" }, { "field": "comparator", "quote": "Herein, we describe the case of an elderly male who presented with painless hematochezia." }, { "field": "primaryOutcome", "quote": "Because of continuing bleeding, the patient required laparoscopic-assisted right hemicolectomy to resect the mass." }, { "field": "result", "quote": "Both gross and microscopic pathology were consistent with lipoma at the ileocecal valve." }, { "field": "result", "quote": "a rare case of an ulcerated ileocecal valve lipoma presenting as lower gastrointestinal bleeding that was treated successfully with laparoscopic resection" } ] }, { "id": "pmid:19119488", "pmid": "19119488", "doi": null, "nctId": null, "pmcid": null, "title": "Rapidly growing giant solitary cavernous hemangioma in a patient with ulcerative colitis", "firstAuthor": "Erkan", "multipleAuthors": true, "journal": "Turk J Gastroenterol", "year": 2008, "design": "case-series", "n": 1, "nField": "reported", "population": "61-year-old man with ulcerative colitis who had painless rectal bleeding", "intervention": "surgical excision of the rectal mass", "comparator": "none", "primaryOutcome": "cause of painless rectal bleeding and outcome after removal", "result": "a rapidly growing cavernous hemangioma was found and removed, explaining the bleeding", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common this cause is or how treatment generally works", "directness": "indirect", "limitations": "single case report; findings may not generalize to other people with painless rectal bleeding", "followUp": "", "plainFinding": "Rare hemangioma caused painless bleeding", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/19119488/", "sourceText": "Cavernous hemangiomas are rare lesions of the colon that usually present with painless, recurrent bleeding. Hemangiomas can be capillary or cavernous type, and 80% of rectal hemangiomas are cavernous type. Ulcerative colitis is an inflammatory disorder that affects the rectum and, occasionally, the whole colon. Diarrhea, rectal bleeding and mucous discharge characterize ulcerative colitis. We present a 61-year-old man with painless rectal bleeding due to a solitary cavernous hemangioma of the rectum. He had been diagnosed with distal type ulcerative colitis in 2003. He was asymptomatic under mesalazine treatment until May 2005, when he presented with new onset bright red rectal bleeding and mucous discharge, despite still defecating normal stools once a day. Rectosigmoidoscopic examination revealed mucosal hyperemia, edema, granularity, and a hyperemic, friable mass lesion 5x4 cm in diameter in the rectum. Following excision, histopathologic examination of the mass was consistent with cavernous hemangioma. There was a six-month period between the rectosigmoidoscopy in which the cavernous hemangioma (5x4 cm in diameter) was detected and the former rectosigmoidoscopy with no reported hemangioma. Thus, this was considered a rapidly growing cavernous hemangioma. Intralesional microhemorrhages may cause rapid enlargement of the hemangiomas. Ulcerative colitis is characterized by inflammation, which may interfere with vascular integrity and augment intralesional microhemorrhage. We postulate that the inflammatory background of ulcerative colitis may have accelerated intralesional hemorrhage and growth of this coincidental rectal cavernous hemangioma. To the best of our knowledge, this is the only case of this sort in the literature.", "provenance": [ { "field": "population", "quote": "We present a 61-year-old man with painless rectal bleeding due to a solitary cavernous hemangioma of the rectum." }, { "field": "n", "quote": "We present a 61-year-old man with painless rectal bleeding due to a solitary cavernous hemangioma of the rectum." }, { "field": "intervention", "quote": "Following excision, histopathologic examination of the mass was consistent with cavernous hemangioma." }, { "field": "comparator", "quote": "Following excision, histopathologic examination of the mass was consistent with cavernous hemangioma." }, { "field": "primaryOutcome", "quote": "He had been diagnosed with distal type ulcerative colitis in 2003." }, { "field": "result", "quote": "Following excision, histopathologic examination of the mass was consistent with cavernous hemangioma." } ] }, { "id": "pmid:18553195", "pmid": "18553195", "doi": "10.1007/s00268-008-9627-4", "nctId": null, "pmcid": null, "title": "Circular stapled hemorrhoidopexy: experience of a single center with 445 cases", "firstAuthor": "Uras", "multipleAuthors": true, "journal": "World J Surg", "year": 2008, "design": "case-series", "n": 445, "nField": "reported", "population": "people with second to fourth degree hemorrhoids", "intervention": "circular stapled hemorrhoidopexy (surgery for hemorrhoids)", "comparator": "none (single group followed over time)", "primaryOutcome": "complications, residual symptoms, and recurrence after surgery", "result": "low recurrence (1%) and complication rates, with a relatively painless recovery, though some patients had bleeding, itching, or other symptoms afterward", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this is a single-center case series without a comparison group, so it cannot show whether the surgery itself caused the outcomes seen.", "directness": "indirect", "limitations": "No control group; abstract does not address painless rectal bleeding without hemorrhoid surgery as a cause.", "followUp": "23 months", "plainFinding": "Surgery for hemorrhoids, low complication rates.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/18553195/", "sourceText": "This study was designed to review the results of circular stapled hemorrhoidopexy (CSH) in the management of second-, third-, and fourth-degree hemorrhoidal disease. The medical records of 483 patients who had undergone circular stapled hemorrhoidopexy for symptomatic hemorrhoidal disease from June 2001 to September 2006 were evaluated. Data regarding complications, residual symptoms, and recurrence were collected. The study included 445 patients (283 men, 162 women) between 22 and 74 years old (median age 39 years). This constituted 92% of all patients. Concomitant lateral internal sphincterotomy, skin tags' excision, and thrombus removal were done in 106 (24.0%), 83 (18.5%), and 20 (4.5%) patients, respectively. The median operating time was 24 minutes (10-45 minutes). The median hospital stay was 40 hours (11-72 hours). Complications during the first 24 hours were fecal urgency (25%), urinary retention (8%), and rectal bleeding (1%). Pruritus ani (21%), thrombosed external hemorrhoids (4%), staple line stenosis (2%), rectal bleeding (2%), anal fissure (1%), and persistent skin tags (3%) were the symptoms seen during the long-term follow-up. The median follow-up was 23 months (6-70 months). The recurrence rate was 1%. Circular stapled hemorrhoidopexy can be safely performed with low recurrence and complication rates while offering a relatively painless postoperative period for the patient.", "provenance": [ { "field": "population", "quote": "second-, third-, and fourth-degree hemorrhoidal disease" }, { "field": "intervention", "quote": "circular stapled hemorrhoidopexy (CSH)" }, { "field": "comparator", "quote": "The medical records of 483 patients who had undergone circular stapled hemorrhoidopexy for symptomatic hemorrhoidal disease" }, { "field": "primaryOutcome", "quote": "Data regarding complications, residual symptoms, and recurrence were collected." }, { "field": "result", "quote": "Circular stapled hemorrhoidopexy can be safely performed with low recurrence and complication rates while offering a relatively painless postoperative period for the patient." }, { "field": "n", "quote": "The study included 445 patients (283 men, 162 women)" }, { "field": "followUp", "quote": "The median follow-up was 23 months (6-70 months)." } ] }, { "id": "pmid:18472711", "pmid": "18472711", "doi": null, "nctId": null, "pmcid": null, "title": "Life threatening rectal bleeding due to a giant solitary juvenile polyp in a child. A case report and review of the literature", "firstAuthor": "Dahshan", "multipleAuthors": false, "journal": "J Okla State Med Assoc", "year": 2008, "design": "case-series", "n": 1, "nField": "reported", "population": "A nine-year-old boy with painless rectal bleeding", "intervention": "Colonoscopy with polyp resection", "comparator": "None", "primaryOutcome": "Cause of massive painless rectal bleeding and outcome after treatment", "result": "A giant juvenile polyp was found and removed, resolving the bleeding", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, which cannot show how common this cause is or how well treatment works in general.", "directness": "direct", "limitations": "Single case report; evaluation was delayed; no comparison group", "followUp": "", "plainFinding": "", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/18472711/", "sourceText": "Juvenile polyps (JP) are a recognized cause of painless rectal bleeding in preschool age children. They are often solitary, pedunculated and small in size but may occasionally grow to large sizes or occur in great numbers, as in juvenile polyposis syndrome. A nine-year-old previously healthy Hispanic boy with prior history of recurrent abdominal pain and vomiting for 4 months presented with sudden onset of massive painless hematochezia and hemorrhagic shock. Following blood transfusion the bleeding spontaneously stopped. Though further evaluation was delayed due to family reticence, eventually colonoscopy was performed and revealed a giant pedunculated solitary polyp in the traverse colon. After resection, the polyp measured 3.2 x 2.2 x 1.7 cm. Histological evaluation revealed juvenile retention polyp. Giant juvenile polyps (greater than 30 mm) are exceedingly rare in children. Life threatening rectal bleeding due to giant solitary juvenile polyp has rarely been previously reported in children. Spontaneous cessation of bleeding should not delay the endoscopic evaluation. In a child with massive hematochesia, JP should still be considered in the differential diagnosis, as highlighted by this case.", "provenance": [ { "field": "population", "quote": "A nine-year-old previously healthy Hispanic boy with prior history of recurrent abdominal pain and vomiting for 4 months presented with sudden onset of massive painless hematochezia and hemorrhagic shock." }, { "field": "n", "quote": "A nine-year-old previously healthy Hispanic boy" }, { "field": "intervention", "quote": "colonoscopy was performed and revealed a giant pedunculated solitary polyp in the traverse colon. After resection" }, { "field": "comparator", "quote": "Following blood transfusion the bleeding spontaneously stopped." }, { "field": "primaryOutcome", "quote": "Histological evaluation revealed juvenile retention polyp." }, { "field": "result", "quote": "After resection, the polyp measured 3.2 x 2.2 x 1.7 cm. Histological evaluation revealed juvenile retention polyp." } ] }, { "id": "pmid:18330577", "pmid": "18330577", "doi": "10.1007/s00384-008-0466-4", "nctId": null, "pmcid": null, "title": "Cavernous, arteriovenous, and mixed hemangioma-lymphangioma of the rectosigmoid: rare causes of rectal bleeding--case series and review of the literature", "firstAuthor": "Sylla", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 2008, "design": "case-series", "n": 3, "nField": "reported", "population": "people with rectal bleeding caused by rare vascular malformations of the rectosigmoid colon", "intervention": "surgical removal of the affected bowel segment", "comparator": "no comparator (case series)", "primaryOutcome": "clinical presentation and outcome after surgical treatment", "result": "surgery removed the malformations, but diagnosis was often delayed for years due to misdiagnosis as hemorrhoids or inflammatory bowel disease", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is just a report of three patients' cases, not a controlled study, so it cannot show whether treatment works.", "directness": "direct", "limitations": "Only three cases reported, no comparison group, and no systematic data on how well treatment worked.", "followUp": "", "plainFinding": "Rare blood vessel growths can cause painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/18330577/", "sourceText": "INTRODUCTION: Cavernous hemangiomas of the sigmoid colon and rectum are uncommon vascular malformations usually found in young adults with a long history of episodic and painless rectal bleeding. Alternatively, they may present with massive life-threatening hemorrhage. DISCUSSION: We report three cases of hemangioma of the rectosigmoid including one case of cavernous hemangioma, one case of arteriovenous hemangioma, and one case of hemangiolymphangiomatosis with emphasis on clinical presentation, radiologic, operative, and pathologic findings. Definitive treatment consists of complete resection with a sphincter-preserving procedure or abdominoperineal resection, based on extent of disease. CONCLUSION: Therapy is typically delayed by several years in these patients due to erroneous diagnosis and failed treatment of hemorrhoids and inflammatory bowel disease. Relative to hemangiomas, lymphangiomas of the rectosigmoid are even more rare and when symptomatic, present with rectal bleeding and pelvic pain.", "provenance": [ { "field": "population", "quote": "Cavernous hemangiomas of the sigmoid colon and rectum are uncommon vascular malformations usually found in young adults with a long history of episodic and painless rectal bleeding." }, { "field": "n", "quote": "We report three cases of hemangioma of the rectosigmoid" }, { "field": "intervention", "quote": "Definitive treatment consists of complete resection with a sphincter-preserving procedure or abdominoperineal resection, based on extent of disease." }, { "field": "comparator", "quote": "We report three cases of hemangioma of the rectosigmoid including one case of cavernous hemangioma, one case of arteriovenous hemangioma, and one case of hemangiolymphangiomatosis" }, { "field": "primaryOutcome", "quote": "with emphasis on clinical presentation, radiologic, operative, and pathologic findings" }, { "field": "result", "quote": "Therapy is typically delayed by several years in these patients due to erroneous diagnosis and failed treatment of hemorrhoids and inflammatory bowel disease." } ] }, { "id": "pmid:17266878", "pmid": "17266878", "doi": "10.1157/13097447", "nctId": null, "pmcid": null, "title": "[An atypical case of massive gastrointestinal hemorrhage]", "firstAuthor": "Domínguez Jiménez", "multipleAuthors": true, "journal": "Gastroenterol Hepatol", "year": 2007, "design": "case-series", "n": 1, "nField": "reported", "population": "29-year-old woman with severe gastrointestinal bleeding", "intervention": "none (diagnostic workup and surgery)", "comparator": "none", "primaryOutcome": "cause of severe gastrointestinal bleeding (melena)", "result": "diagnosed with a jejunal gastrointestinal stromal tumor (GIST), treated with surgical removal", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how common this cause is or how well treatment works in general.", "directness": "direct", "limitations": "Only one patient described; no comparison group or statistical analysis.", "followUp": "", "plainFinding": "Rare tumor caused painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/17266878/", "sourceText": "Gastrointestinal stromal tumors (GIST) are an infrequent cause (<1%) of severe gastrointestinal hemorrhage. Treatment is mainly surgical through complete tumoral resection. We report the case of a 29-year-old woman who presented to the emergency room with severe gastrointestinal bleeding manifested by melena. On physical examination the patient had a painless, palpable mass in the left abdomen. Esophagogastroduodenoscopy, computed tomography, angiography and urgent surgical intervention led to diagnosis of a jejunal GIST.", "provenance": [ { "field": "population", "quote": "a 29-year-old woman who presented to the emergency room with severe gastrointestinal bleeding manifested by melena" }, { "field": "n", "quote": "We report the case of a 29-year-old woman" }, { "field": "primaryOutcome", "quote": "severe gastrointestinal hemorrhage" }, { "field": "intervention", "quote": "Esophagogastroduodenoscopy, computed tomography, angiography and urgent surgical intervention" }, { "field": "result", "quote": "led to diagnosis of a jejunal GIST" }, { "field": "comparator", "quote": "Treatment is mainly surgical through complete tumoral resection." } ] }, { "id": "pmid:17205412", "pmid": "17205412", "doi": null, "nctId": null, "pmcid": null, "title": "Mechanical bowel obstruction due to colonic hemangioma: report of a case", "firstAuthor": "Demirbaş", "multipleAuthors": true, "journal": "Turk J Gastroenterol", "year": 2006, "design": "case-series", "n": 1, "nField": "reported", "population": "a 62-year-old man with bowel blockage symptoms", "intervention": "surgery to remove part of the colon (transverse colectomy)", "comparator": "none", "primaryOutcome": "diagnosis of the cause and outcome after surgery", "result": "surgery found a benign blood vessel tumor (cavernous hemangioma) causing blockage, and the patient recovered with no complications", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how common this cause is or how well treatment works in general.", "directness": "indirect", "limitations": "Only one patient; this case had bowel obstruction rather than just bleeding, and the abstract does not address painless bleeding as the main problem.", "followUp": "", "plainFinding": "Rare colon tumor caused blockage, bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/17205412/", "sourceText": "Colon hemangiomas are rare benign vascular lesions which are usually seen in teenagers. The frequent presentation is repetitive painless rectal bleeding. Colonic hemangiomas are occasionally found in the rectosigmoid area. A 62-year-old male patient was admitted to the hospital with the complaints of mechanical bowel obstruction. The radiological imaging techniques revealed a transverse colon tumor. Consequently, the patient was operated, and transverse colectomy and end-to-end anastomosis were performed. No postoperative complications occurred. The pathologic examination revealed cavernous hemangioma of the transverse colon. This report describes a very rare case of bowel obstruction due to colonic hemangioma.", "provenance": [ { "field": "n", "quote": "A 62-year-old male patient was admitted to the hospital with the complaints of mechanical bowel obstruction." }, { "field": "population", "quote": "A 62-year-old male patient was admitted to the hospital with the complaints of mechanical bowel obstruction." }, { "field": "intervention", "quote": "transverse colectomy and end-to-end anastomosis were performed" }, { "field": "comparator", "quote": "No postoperative complications occurred." }, { "field": "primaryOutcome", "quote": "The pathologic examination revealed cavernous hemangioma of the transverse colon." }, { "field": "result", "quote": "The pathologic examination revealed cavernous hemangioma of the transverse colon. This report describes a very rare case of bowel obstruction due to colonic hemangioma." }, { "field": "population", "quote": "The frequent presentation is repetitive painless rectal bleeding." } ] }, { "id": "pmid:16671513", "pmid": "16671513", "doi": null, "nctId": null, "pmcid": null, "title": "[Meckel's diverticulum as a cause of massive rectal bleeding]", "firstAuthor": "Fernández-Pineda", "multipleAuthors": true, "journal": "Cir Pediatr", "year": 2006, "design": "case-series", "n": 1, "nField": "reported", "population": "a three month old baby boy", "intervention": "none (diagnostic workup and surgery for bleeding)", "comparator": "", "primaryOutcome": "cause and management of massive painless rectal bleeding", "result": "Meckel's diverticulum was found to be the cause of the bleeding, treated with blood transfusion, stabilization, and emergency surgery", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single case report, so it cannot show how common this cause is or how well treatment works in general.", "directness": "direct", "limitations": "Only one patient was described, so findings may not apply to others; no comparison group or outcome tracking.", "followUp": "", "plainFinding": "Rare bowel defect caused painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/16671513/", "sourceText": "A fit three months old male baby was admitted in our hospital with a history of massive painless fresh rectal bleeding. Blood transfusion, hemodynamic stabilization and emergency laparotomy were necessary because of the high suspect of Meckel's diverticulum as the cause of bleeding. It is an uncommon case due to the low age of the patient and the severity of clinical presentation.", "provenance": [ { "field": "population", "quote": "A fit three months old male baby was admitted in our hospital with a history of massive painless fresh rectal bleeding." }, { "field": "intervention", "quote": "Blood transfusion, hemodynamic stabilization and emergency laparotomy were necessary because of the high suspect of Meckel's diverticulum as the cause of bleeding." }, { "field": "primaryOutcome", "quote": "history of massive painless fresh rectal bleeding" }, { "field": "result", "quote": "Blood transfusion, hemodynamic stabilization and emergency laparotomy were necessary because of the high suspect of Meckel's diverticulum as the cause of bleeding." }, { "field": "n", "quote": "A fit three months old male baby was admitted in our hospital" } ] }, { "id": "pmid:20011316", "pmid": "20011316", "doi": "10.1055/s-2006-942350", "nctId": null, "pmcid": "PMC2780108", "title": "Hemangiomas of the pelvis", "firstAuthor": "Tan", "multipleAuthors": true, "journal": "Clin Colon Rectal Surg", "year": 2006, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with rectal/colon hemangiomas causing blood in stool", "intervention": "surgical resection preserving sphincters", "comparator": "no comparator discussed", "primaryOutcome": "diagnosis and treatment of painless rectal bleeding due to hemangiomas", "result": "describes hemangiomas as a rare, often misdiagnosed cause of painless rectal bleeding, with diagnosis via endoscopy/imaging and treatment by sphincter-sparing surgery", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a descriptive overview of a condition, not a study testing a treatment's effect, so it cannot show whether an intervention works.", "directness": "direct", "limitations": "No study design, patient numbers, or outcome data are given; this is a general description of the condition and treatment approach.", "followUp": "", "plainFinding": "Rare hemangiomas can cause painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20011316/", "sourceText": "Hemangiomas of the colon and rectum are rare but often misdiagnosed causes of hematochezia. They are characterized by the clinical triad of recurrent episodes of painless rectal bleeding, multiple ectopic phleboliths on plain radiographs, and cutaneous hemangiomas. The majority of these tumors involve the rectosigmoid region. Diffuse cavernous lesions are the most common histological type. Endoscopy is important to define the extent and number of lesions. Imaging by computed tomography or magnetic resonance imaging is used to define invasion into pelvic structures. Surgical resection with preservation of the sphincters is the recommended treatment.", "provenance": [ { "field": "population", "quote": "Hemangiomas of the colon and rectum are rare but often misdiagnosed causes of hematochezia." }, { "field": "primaryOutcome", "quote": "recurrent episodes of painless rectal bleeding, multiple ectopic phleboliths on plain radiographs, and cutaneous hemangiomas" }, { "field": "intervention", "quote": "Surgical resection with preservation of the sphincters is the recommended treatment." }, { "field": "comparator", "quote": "Surgical resection with preservation of the sphincters is the recommended treatment." }, { "field": "result", "quote": "Hemangiomas of the colon and rectum are rare but often misdiagnosed causes of hematochezia." } ] }, { "id": "pmid:16552295", "pmid": "16552295", "doi": "10.1097/00001610-200601000-00003", "nctId": null, "pmcid": null, "title": "Diagnosis and management of gastrointestinal polyps: pediatric considerations", "firstAuthor": "Attard", "multipleAuthors": true, "journal": "Gastroenterol Nurs", "year": 2006, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "Children with painless rectal bleeding", "intervention": "Diagnosis and removal of colorectal polyps", "comparator": "No comparator described", "primaryOutcome": "Identifying which patients need follow-up for polyp syndromes versus those who don't", "result": "Painless bright red rectal bleeding is the classic sign of colorectal polyps in children; most are isolated and don't need further monitoring, but some rare syndromes require follow-up", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a narrative review describing typical presentations and management guidance, not a study testing a treatment or reporting original outcome data.", "directness": "direct", "limitations": "No original patient data, sample size, or outcome statistics are reported; it is a general review article.", "followUp": "", "plainFinding": "Painless bleeding often from harmless childhood polyps.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/16552295/", "sourceText": "Painless, bright red, rectal bleeding with normal stool frequency and consistency is the hallmark presentation of colorectal polyps at any age. Most polyps in children are sporadic, usually isolated, colorectal juvenile polyps that do not require any further surveillance after they are removed. There is, however, increasing recognition of syndromes, including familial adenomatous polyposis, juvenile polyposis coli, Peutz-Jeghers syndrome, and infrequent conditions, such as PTEN hamartoma and hereditary mixed polyposis syndromes. The aim of this review is to allow the reader to correctly identify the patients who do not require follow-up and the smaller group of patients who do require follow-up because of syndromic polyp conditions.", "provenance": [ { "field": "population", "quote": "Painless, bright red, rectal bleeding with normal stool frequency and consistency is the hallmark presentation of colorectal polyps at any age." }, { "field": "intervention", "quote": "isolated, colorectal juvenile polyps that do not require any further surveillance after they are removed" }, { "field": "primaryOutcome", "quote": "to correctly identify the patients who do not require follow-up and the smaller group of patients who do require follow-up because of syndromic polyp conditions" }, { "field": "result", "quote": "Most polyps in children are sporadic, usually isolated, colorectal juvenile polyps that do not require any further surveillance after they are removed." }, { "field": "comparator", "quote": "There is, however, increasing recognition of syndromes, including familial adenomatous polyposis, juvenile polyposis coli, Peutz-Jeghers syndrome, and infrequent conditions, such as PTEN hamartoma and hereditary mixed polyposis syndromes." } ] }, { "id": "pmid:16276441", "pmid": "16276441", "doi": null, "nctId": null, "pmcid": null, "title": "Capsule endoscopy for gastrointestinal bleeding with an obscure etiology", "firstAuthor": "Chao", "multipleAuthors": true, "journal": "J Formos Med Assoc", "year": 2005, "design": "case-series", "n": 35, "nField": "reported", "population": "adults with unexplained gastrointestinal bleeding after normal upper endoscopy and colonoscopy", "intervention": "capsule endoscopy (a swallowed camera pill) to look for a bleeding source", "comparator": "no comparison group", "primaryOutcome": "whether the capsule endoscopy found a cause of the bleeding", "result": "abnormal findings were seen in 89% of patients, and a clear cause explaining their bleeding was found in 57.2%, most often small blood vessel abnormalities (angiodysplasia) or Crohn's disease", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a small single-group study without a comparison group, so it shows the test can find causes of bleeding but not how it compares to other methods.", "directness": "indirect", "limitations": "small sample size, single center, no control group, and bowel preparation was not standardized for all patients", "followUp": "up to 2 months after ingestion", "plainFinding": "Found bleeding source in most patients", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/16276441/", "sourceText": "BACKGROUND AND PURPOSE: Capsule endoscopy (CE) is a new diagnostic modality that is being utilized with increasing frequency for examination of lesions suspected to be of small bowel origin. The most common indication for CE is obscure gastrointestinal bleeding. This study investigated the safety and diagnostic value of CE in patients with obscure gastrointestinal bleeding. METHODS: From February 1 to October 30, 2003, 35 patients with obscure gastrointestinal bleeding among 43 consecutive patients with suspected small bowel pathology were enrolled. The mean age of the patients was 50.5 years (range, 24-81 years). A negative panendoscopy and colonoscopic study were required for study eligibility. An M2A video capsule endoscope was swallowed by each patient after an overnight fast if plain abdominal radiograph done 1 day prior to the procedure was negative for obstruction. Bowel preparation using a mixed solution containing magnesium carbonate, citric acid anhydrous and potassium bicarbonate, and bisacodyl was performed only in selected patients. RESULTS: Abnormal findings were noted in 31 of 35 patients (89%), 20 (57.2%) of whom had gastrointestinal pathology explaining their symptoms. Only 12 (34%) of the 20 patients had lesions solely in the small bowel. Angiodysplasia was the most common source of bleeding (37%), followed by Crohn's disease (14%). Other findings included Osler-Weber-Rendu's disease, gastrointestinal stromal tumor, vascular ectasia and small bowel diverticulum. Three capsules became lodged and did not provide images during subsequent transit through the colon, but serial abdominal plain radiographs done every 3 days after capsule ingestion showed passage of the capsules had occurred by 1 week. No discomfort or side effects were noted up to 2 months after ingestion. CONCLUSION: CE is a safe, painless and effective method for diagnosing obscure gastrointestinal bleeding. A final diagnosis was reached in more than one half of the patients and positively affected treatment. The capsule produced clear and recognizable images of lesions even without bowel preparation. If done early, CE can aid in directing proper management in patients with suspected small bowel pathology.", "provenance": [ { "field": "n", "quote": "35 patients with obscure gastrointestinal bleeding among 43 consecutive patients with suspected small bowel pathology were enrolled" }, { "field": "population", "quote": "patients with obscure gastrointestinal bleeding" }, { "field": "population", "quote": "A negative panendoscopy and colonoscopic study were required for study eligibility." }, { "field": "intervention", "quote": "An M2A video capsule endoscope was swallowed by each patient" }, { "field": "comparator", "quote": "This study investigated the safety and diagnostic value of CE in patients with obscure gastrointestinal bleeding." }, { "field": "primaryOutcome", "quote": "Abnormal findings were noted in 31 of 35 patients (89%), 20 (57.2%) of whom had gastrointestinal pathology explaining their symptoms." }, { "field": "result", "quote": "Angiodysplasia was the most common source of bleeding (37%), followed by Crohn's disease (14%)." }, { "field": "result", "quote": "No discomfort or side effects were noted up to 2 months after ingestion." } ] }, { "id": "pmid:16024315", "pmid": "16024315", "doi": "10.1016/S1015-9584(09)60342-0", "nctId": null, "pmcid": null, "title": "Stapled haemorrhoidectomy: bothersome staple line bleeding", "firstAuthor": "Koh", "multipleAuthors": true, "journal": "Asian J Surg", "year": 2005, "design": "retrospective", "n": 39, "nField": "reported", "population": "patients who had stapled haemorrhoidectomy surgery for prolapsing haemorrhoids", "intervention": "stapled haemorrhoidectomy procedure", "comparator": "patients without staple line bleeding noted during surgery", "primaryOutcome": "bleeding from the staple line during and after surgery", "result": "44% had bleeding during surgery and 23% were readmitted for bleeding after surgery", "resultDirection": "harm", "quality": "low", "qualityWhy": "This is a small retrospective review of surgical records without a control group, so it can't prove cause or compare treatments reliably.", "directness": "indirect", "limitations": "Retrospective design, no comparison group of a different treatment, small sample size.", "followUp": "", "plainFinding": "Bleeding is a common surgery complication.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/16024315/", "sourceText": "BACKGROUND: The stapled haemorrhoidectomy procedure has been popularized as a painless and effective treatment for prolapsing haemorrhoidal disease. We have noted that staple line bleeding is a contributory factor to postoperative morbidity. METHODS: This was a retrospective analysis of the clinical records of consecutive stapled haemorrhoidectomy procedures performed in patients over a 1-year period. The outpatient, operative and inpatient records were reviewed. We assessed the incidence of intraoperative staple line bleeding, its management and early postoperative outcomes in our patients undergoing stapled haemorrhoidectomy. RESULTS: From March 2000 to March 2001, 39 stapled haemorrhoidectomy procedures were performed. Intraoperative staple line bleeding was recorded in 17 patients (44%) and suture reinforcement of this staple line was required in 12 (31%). Nine patients (23%) were admitted for postoperative per rectal bleeding, four of whom required surgical haemostasis of bleeding points along the staple line. Delayed secondary haemorrhage was seen in one patient. The incidence of postoperative bleeding in patients with noted staple line bleeding was 35%, compared with 14% in those without evidence of bleeding. CONCLUSION: Staple line bleeding is a technical difficulty and complication associated with stapled haemorrhoidectomy. It should be managed with meticulous haemostatic suture placement in order to avoid postoperative bleeding and the morbidity of re-operation for haemostasis.", "provenance": [ { "field": "n", "quote": "39 stapled haemorrhoidectomy procedures were performed" }, { "field": "population", "quote": "consecutive stapled haemorrhoidectomy procedures performed in patients over a 1-year period" }, { "field": "intervention", "quote": "stapled haemorrhoidectomy procedure" }, { "field": "comparator", "quote": "compared with 14% in those without evidence of bleeding" }, { "field": "primaryOutcome", "quote": "the incidence of intraoperative staple line bleeding, its management and early postoperative outcomes" }, { "field": "result", "quote": "Intraoperative staple line bleeding was recorded in 17 patients (44%)" }, { "field": "result", "quote": "Nine patients (23%) were admitted for postoperative per rectal bleeding" } ] }, { "id": "pmid:15578519", "pmid": "15578519", "doi": "10.1053/j.gastro.2004.08.051", "nctId": null, "pmcid": null, "title": "BRAF mutations distinguish anorectal from cutaneous melanoma at the molecular level", "firstAuthor": "Helmke", "multipleAuthors": true, "journal": "Gastroenterology", "year": 2004, "design": "case-series", "n": 19, "nField": "reported", "population": "people with anorectal melanoma, a rare tumor near the anus/rectum", "intervention": "genetic testing of tumor tissue for BRAF and NRAS gene mutations", "comparator": "cutaneous (skin) melanoma mutation rates", "primaryOutcome": "presence of BRAF or NRAS gene mutations in the tumor", "result": "BRAF mutations found in 2 of 19 anorectal melanoma cases, no NRAS mutations, and the common skin-melanoma mutation was absent, showing a different mutation pattern than skin melanoma", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a very small case series of tumor tissue looking at genetics, not a treatment study, so it says little about the causes of rectal bleeding in general.", "directness": "indirect", "limitations": "Very small number of cases (19), focused only on one rare tumor type, and purely molecular/genetic analysis rather than a study of bleeding causes or outcomes.", "followUp": "", "plainFinding": "Anorectal melanoma genetics differ from skin melanoma.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/15578519/", "sourceText": "BACKGROUND & AIMS: Anorectal melanoma (AM) is a rare but highly malignant tumor, displaying histologic and immunohistochemical features very similar to cutaneous melanoma (CM). Because BRAF mutations were recently identified in the majority of CM and nevi, we investigated AM for BRAF mutations and mutations of NRAS , an additional component of the MAPK-signalling pathway. METHODS: DNA from formalin-fixed and paraffin-embedded AM was PCR amplified and sequenced. RESULTS: We detected BRAF mutations in 2 of 19 cases and NRAS mutations in none of the cases. Mutations in exon 15 of BRAF were present in only 1 tumor (1 of 19 cases). The A1800T base exchange represented a novel mutation and resulted in a K600N transition in an AM from a 96-year-old white man who presented with rectal bleeding and painful sitting of a few weeks' duration. The second positive AM case, a 69-year-old white man who presented with painless rectal bleeding and clinical symptoms of an intestinal constipation showed a novel missense mutation (C1327T leading to R443W conversion) in BRAF exon 11. None of the AM cases displayed the oncogenic V599E mutation preponderating in CM. CONCLUSIONS: With regard to the frequency of V599E BRAF mutations, AM significantly differs from CM (P < or = .0001), which suggests that BRAF mutations distinguish anorectal from cutaneous melanoma at the molecular level.", "provenance": [ { "field": "n", "quote": "We detected BRAF mutations in 2 of 19 cases and NRAS mutations in none of the cases." }, { "field": "population", "quote": "Anorectal melanoma (AM) is a rare but highly malignant tumor" }, { "field": "intervention", "quote": "DNA from formalin-fixed and paraffin-embedded AM was PCR amplified and sequenced." }, { "field": "comparator", "quote": "Because BRAF mutations were recently identified in the majority of CM and nevi, we investigated AM for BRAF mutations" }, { "field": "primaryOutcome", "quote": "we investigated AM for BRAF mutations and mutations of NRAS" }, { "field": "result", "quote": "With regard to the frequency of V599E BRAF mutations, AM significantly differs from CM (P < or = .0001), which suggests that BRAF mutations distinguish anorectal from cutaneous melanoma at the molecular level." } ] }, { "id": "pmid:15148618", "pmid": "15148618", "doi": "10.1007/s00383-004-1194-7", "nctId": null, "pmcid": null, "title": "Juvenile colorectal polyps in children: experience in Pakistan", "firstAuthor": "Mandhan", "multipleAuthors": false, "journal": "Pediatr Surg Int", "year": 2004, "design": "case-series", "n": 129, "nField": "reported", "population": "Children aged 14 years or younger in Pakistan who had colorectal polyps", "intervention": "Removal of colorectal polyps via proctosigmoidoscopy", "comparator": "No comparison group", "primaryOutcome": "Successful polyp removal and recurrence of polyps", "result": "All polyps were successfully removed, with recurrence in 7 children within 1 year", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is an uncontrolled case series describing one group of children, so it can't compare treatments or rule out other causes of bleeding.", "directness": "indirect", "limitations": "No control group, retrospective case series, limited to children, no statistical comparison of treatments", "followUp": "1 year", "plainFinding": "Painless bleeding often caused by childhood polyps.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/15148618/", "sourceText": "Juvenile colorectal polyps are the most common cause of pediatric hematochezia and contribute to significant morbidity if not treated early. This report describes an experience with juvenile colorectal polyps in children (< or =14 years) from Pakistan. In a 3-year period, 154 polyps were documented in 129 children. The mean age at presentation was 5.2 years, with a male predominance. Most children presented with painless rectal bleeding (+/-13 months) associated with other symptoms, such as protrusion of a mass through the anus, diarrhea, and recurrent abdominal pain. Anemia was observed in 54 children, of whom 14 (26%) required blood transfusion before intervention. Diagnosis was made by digital rectal examination, proctosigmoidoscopy, and barium enema. The average distance of a colorectal polyp was 4 cm from the anal verge. In 108 (84%) children the polyps were solitary, whereas 21 patients had more than one polyp (maximum three) at different locations in the rectosigmoid area. All polyps were successfully removed by proctosigmoidoscopy. Histological examination revealed dysplastic changes in one case, while the rest were inflammatory. Recurrence occurred in seven children within 1 year of initial removal. Juvenile colorectal polyps contribute to a substantial morbidity in children and do carry a minimal risk of developing dysplastic changes, and therefore should be removed early.", "provenance": [ { "field": "n", "quote": "154 polyps were documented in 129 children" }, { "field": "population", "quote": "juvenile colorectal polyps in children (< or =14 years) from Pakistan" }, { "field": "intervention", "quote": "All polyps were successfully removed by proctosigmoidoscopy." }, { "field": "comparator", "quote": "This report describes an experience with juvenile colorectal polyps in children" }, { "field": "primaryOutcome", "quote": "Recurrence occurred in seven children within 1 year of initial removal." }, { "field": "result", "quote": "All polyps were successfully removed by proctosigmoidoscopy." }, { "field": "result", "quote": "Recurrence occurred in seven children within 1 year of initial removal." } ] }, { "id": "pmid:12800384", "pmid": "12800384", "doi": null, "nctId": null, "pmcid": null, "title": "Laparoscopy diagnosis and treatment excision of bleeding Meckel's diverticulum in a child: report of one case", "firstAuthor": "Lu", "multipleAuthors": true, "journal": "Acta Paediatr Taiwan", "year": 2003, "design": "case-series", "n": 1, "nField": "reported", "population": "a 1-year-7-month-old boy with painless rectal bleeding for about a year", "intervention": "laparoscopy for diagnosis and surgical removal of Meckel's diverticulum", "comparator": "standard tests like abdominal x-ray, ultrasound, scope exam, and nuclear scan", "primaryOutcome": "successful diagnosis and treatment of the bleeding cause", "result": "laparoscopy found and removed the bleeding Meckel's diverticulum after all other tests came back negative, and the child recovered quickly", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how often this works or compares to other approaches.", "directness": "direct", "limitations": "only one patient; no comparison group; cannot generalize findings", "followUp": "48 hours", "plainFinding": "Painless bleeding from Meckel's diverticulum, fixed by surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/12800384/", "sourceText": "Meckel's diverticulum is a common cause of low gastrointestinal bleeding in childhood. Conventional diagnostic methods including plain abdominal radiographs, abdominal ultrasound, technectium 99m pertechnetate scintigraphy, angiography, and exploratory laparotomy have several limitations. Here, we report that a case of Meckel's diverticulum in a 1-year-7-month-old boy presenting with intermittent episodes of painless low gastrointestinal bleeding for about one year. Despite the traditional studies, including plain abdominal films, abdominal ultrasound, rectosigmoidoscopy and repeated Tc-99m Meckel's scan, all showed negative finding, it was successfully diagnosed along with excision of Meckel's diverticulum by laparoscopy. The patient made a rapid recovery and discharged at 48 hours after the procedure. We emphasize that laparoscopy should be an alternative diagnostic and therapeutic modality of choice in patients suspected of Meckel's diverticulum, especially in pediatric patients who had negative results of all other work-ups.", "provenance": [ { "field": "population", "quote": "a 1-year-7-month-old boy presenting with intermittent episodes of painless low gastrointestinal bleeding for about one year" }, { "field": "intervention", "quote": "successfully diagnosed along with excision of Meckel's diverticulum by laparoscopy" }, { "field": "comparator", "quote": "plain abdominal films, abdominal ultrasound, rectosigmoidoscopy and repeated Tc-99m Meckel's scan, all showed negative finding" }, { "field": "primaryOutcome", "quote": "it was successfully diagnosed along with excision of Meckel's diverticulum by laparoscopy" }, { "field": "result", "quote": "The patient made a rapid recovery and discharged at 48 hours after the procedure." }, { "field": "n", "quote": "a 1-year-7-month-old boy presenting with intermittent episodes of painless low gastrointestinal bleeding for about one year" }, { "field": "followUp", "quote": "discharged at 48 hours after the procedure" } ] }, { "id": "pmid:12352251", "pmid": "12352251", "doi": "10.1097/00008480-200210000-00003", "nctId": null, "pmcid": null, "title": "Gastrointestinal polyps and polyposis syndromes in children", "firstAuthor": "Erdman", "multipleAuthors": true, "journal": "Curr Opin Pediatr", "year": 2002, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "children with gastrointestinal polyps", "intervention": "", "comparator": "", "primaryOutcome": "identifying polyps and polyposis syndromes, and cancer risk", "result": "most polyps in children are isolated and not linked to genetic disease or cancer risk, but some occur in genetic polyposis syndromes with higher cancer risk", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a narrative review summarizing general knowledge, not a study testing a treatment or measuring outcomes in a defined group of patients.", "directness": "direct", "limitations": "no original data, no patient numbers, no methodology described for how conclusions were reached.", "followUp": "", "plainFinding": "Painless rectal bleeding often just a polyp.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/12352251/", "sourceText": "Gastrointestinal polyps are common during childhood and most often present with painless rectal bleeding. Most polyps occur as isolated colonic lesions and are not harbingers of an underlying genetic disorder, nor do they bestow a risk of gastrointestinal cancer. The astute pediatrician must be aware, however, that occasionally polyps may occur in the context of a genetic polyposis disorder characterized by an increase in the life-time risk of cancer in the gastrointestinal tract and other organ systems. This review outlines the major polyposis syndromes affecting children and highlights associated findings that might clue the alert physician to an underlying diagnosis. Recent developments in the understanding of the genetics of each disorder are emphasized.", "provenance": [ { "field": "population", "quote": "Gastrointestinal polyps are common during childhood and most often present with painless rectal bleeding." }, { "field": "result", "quote": "Most polyps occur as isolated colonic lesions and are not harbingers of an underlying genetic disorder, nor do they bestow a risk of gastrointestinal cancer." }, { "field": "result", "quote": "occasionally polyps may occur in the context of a genetic polyposis disorder characterized by an increase in the life-time risk of cancer in the gastrointestinal tract and other organ systems" }, { "field": "primaryOutcome", "quote": "This review outlines the major polyposis syndromes affecting children and highlights associated findings that might clue the alert physician to an underlying diagnosis." } ] }, { "id": "pmid:11668104", "pmid": "11668104", "doi": "10.1136/adc.85.5.404", "nctId": null, "pmcid": "PMC1718983", "title": "Double blind randomised controlled trial of topical glyceryl trinitrate in anal fissure", "firstAuthor": "Kenny", "multipleAuthors": true, "journal": "Arch Dis Child", "year": 2001, "design": "rct", "n": 40, "nField": "reported", "population": "children with a new anal fissure", "intervention": "topical glyceryl trinitrate (GTN) paste plus oral laxatives", "comparator": "placebo paste plus oral laxatives", "primaryOutcome": "pain scores and time to pain-free bowel movements", "result": "no difference between GTN and placebo in pain scores, time to painless defecation, or rate of rectal bleeding", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "it was a randomized trial but very small, with only 40 children recruited and just 31 completing it, so it can't reliably detect small differences.", "directness": "indirect", "limitations": "small sample size, high dropout (31 of 40 completed), and the children studied had anal fissures, which usually cause pain, unlike painless bleeding", "followUp": "16 week study period", "plainFinding": "No benefit over placebo for fissures.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/11668104/", "sourceText": "AIMS: To determine the effectiveness and safety of topical glyceryl trinitrate (GTN) in the management of acute anal fissure in children. METHODS: Individual children were randomised to receive GTN paste or placebo for six weeks in addition to oral senna and lactulose. Patients took laxatives alone for a further 10 weeks. Each week a research nurse telephoned families to assess pain scores and give advice. Main outcome measures were validated standardised pain scores and time to painless defaecation. RESULTS: Forty subjects were recruited from 46 eligible children; 31 children completed the trial (13 in the GTN group and 18 in the placebo group). No differences in the proportion of those achieving pain free defaecation with relation to time were seen between the two groups. Similarly, there were no significant differences in pain scores between the two groups over the 16 week study period. However, in both groups pain scores had decreased significantly. There were no differences in the incidence of rectal bleeding, faecal soiling, presence of visible fissure, skin tag, or faecal loading at outpatient review at the time of recruitment, or at 6 weeks and 16 weeks. No serious adverse effects were observed. CONCLUSIONS: This study suggests that 0.2% GTN paste is ineffective in the treatment of acute anal fissures in childhood. However the overall fissure healing rate is high (84%) with associated reduction in pain scores, suggesting that a nurse based treatment programme can achieve a high rate of fissure healing.", "provenance": [ { "field": "population", "quote": "acute anal fissure in children" }, { "field": "intervention", "quote": "Individual children were randomised to receive GTN paste or placebo for six weeks in addition to oral senna and lactulose." }, { "field": "comparator", "quote": "Individual children were randomised to receive GTN paste or placebo for six weeks in addition to oral senna and lactulose." }, { "field": "primaryOutcome", "quote": "Main outcome measures were validated standardised pain scores and time to painless defaecation." }, { "field": "result", "quote": "No differences in the proportion of those achieving pain free defaecation with relation to time were seen between the two groups." }, { "field": "result", "quote": "there were no significant differences in pain scores between the two groups over the 16 week study period" }, { "field": "result", "quote": "There were no differences in the incidence of rectal bleeding, faecal soiling, presence of visible fissure, skin tag, or faecal loading" }, { "field": "n", "quote": "Forty subjects were recruited from 46 eligible children; 31 children completed the trial" }, { "field": "followUp", "quote": "over the 16 week study period" } ] }, { "id": "pmid:11544540", "pmid": "11544540", "doi": "10.1155/2001/851354", "nctId": null, "pmcid": null, "title": "Dieulafoy's lesions of the rectum: a rare cause of lower gastrointestinal bleeding", "firstAuthor": "Enns", "multipleAuthors": false, "journal": "Can J Gastroenterol", "year": 2001, "design": "case-series", "n": 1, "nField": "reported", "population": "72-year-old man with massive painless rectal bleeding", "intervention": "Endoscopic treatment with adrenaline injection and electrocautery", "comparator": "No comparator described", "primaryOutcome": "Stopping the bleeding", "result": "Bleeding completely stopped after endoscopic treatment", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how often this treatment works for others.", "directness": "direct", "limitations": "Only one patient described; no comparison group; long-term outcomes beyond this case not reported.", "followUp": "", "plainFinding": "Bleeding stopped after treatment.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/11544540/", "sourceText": "Dieulafoy's lesions located outside of the stomach are rare occurrences. Lesions found within the colon typically present with painless, massive hematochezia (ie, greater than 5 U). If they can be accurately located, endoscopic therapy in the form of adrenaline injection, sclerotherapy or cauterization appears to have long term success. The present report details the case of a 72-year-old man who presented with massive hematochezia and who was discovered to have a Dieulafoy's lesion within the rectum. The lesion was located just distal to a previous surgical anastomosis, and was successfully treated with adrenaline and electrocautery. Colonic Dieulafoy's lesions are rare but should always be considered in the differential diagnosis of massive hematochezia, because endoscopic therapy appears to result in complete cessation of bleeding.", "provenance": [ { "field": "population", "quote": "a 72-year-old man who presented with massive hematochezia and who was discovered to have a Dieulafoy's lesion within the rectum" }, { "field": "intervention", "quote": "successfully treated with adrenaline and electrocautery" }, { "field": "comparator", "quote": "The present report details the case of a 72-year-old man who presented with massive hematochezia" }, { "field": "primaryOutcome", "quote": "endoscopic therapy appears to result in complete cessation of bleeding" }, { "field": "result", "quote": "was successfully treated with adrenaline and electrocautery" }, { "field": "n", "quote": "a 72-year-old man" } ] }, { "id": "pmid:11419816", "pmid": "11419816", "doi": "10.1111/j.1572-0241.2001.03860.x", "nctId": null, "pmcid": null, "title": "Experience with juvenile polyps in North American children: the need for pancolonoscopy", "firstAuthor": "Gupta", "multipleAuthors": true, "journal": "Am J Gastroenterol", "year": 2001, "design": "retrospective", "n": 184, "nField": "reported", "population": "children with juvenile colon polyps", "intervention": "full colonoscopy (pancolonoscopy) examining the whole colon", "comparator": "limited colonoscopy examining only part of the colon", "primaryOutcome": "where polyps were found in the colon and whether proximal polyps were missed", "result": "Painless rectal bleeding was the most common symptom, and full colonoscopy found that about a third of children had polyps higher up in the colon that a limited exam would miss", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a retrospective chart review without a comparison group testing treatment, so it only describes patterns rather than proving what causes painless bleeding or what fixes it.", "directness": "direct", "limitations": "Retrospective design, no control group, based on chart review over 9 years, single type of cause (juvenile polyps) studied.", "followUp": "", "plainFinding": "Painless bleeding often from colon polyps.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/11419816/", "sourceText": "We report a recent experience with juvenile polyps (JP) in a large cohort of North American children to determine if a pancolonoscopy (PC) is needed in all children with suspected polyps. We reviewed hospital charts of all patients with JP seen over a 9-yr period (January, 1990-October, 1998). A total of 331 JP were encountered during 195 procedures in 184 patients (64% males, 88% white, mean age 5.93 yr [range 0.42-15.5 yr], median age 4.84 yr). Painless rectal bleeding was the commonest symptom. PC was performed in 42% (82/195) of procedures, and 177 JP were encountered: 54% (97/177) were in the rectosigmoid colon, 14% (24/177) were in the descending colon, and 32% (56/177) were proximal to the splenic flexure (i.e., proximal polyps). Overall, proximal polyps were seen in 37% (31/82) of PC. Only proximal polyps were noted in 12% (10/82) of PC. Five patients were re-endoscoped after an initial limited examination because of continuing symptoms from proximal polyps. All but one of the polyps had typical features of a JP on histological examination. Though most JP are located in the left colon, a PC should be the initial procedure because: 1) 37% of PC revealed proximal polyps, 2) 32% of polyps were located proximal to splenic flexure, 3) persistence of symptoms from missed proximal polyp(s) necessitates a repeat study with attendant risks, and 4) there is a possibility of malignant transformation in an unidentified JP.", "provenance": [ { "field": "population", "quote": "juvenile polyps (JP) in a large cohort of North American children" }, { "field": "n", "quote": "331 JP were encountered during 195 procedures in 184 patients" }, { "field": "intervention", "quote": "pancolonoscopy (PC) is needed in all children with suspected polyps" }, { "field": "comparator", "quote": "PC was performed in 42% (82/195) of procedures" }, { "field": "primaryOutcome", "quote": "Overall, proximal polyps were seen in 37% (31/82) of PC." }, { "field": "result", "quote": "Painless rectal bleeding was the commonest symptom." }, { "field": "result", "quote": "32% (56/177) were proximal to the splenic flexure (i.e., proximal polyps)" } ] }, { "id": "pmid:23578119", "pmid": "23578119", "doi": "10.1046/j.1463-1318.2000.00141.x", "nctId": null, "pmcid": null, "title": "Rectal bleeding in general and hospital practice; 'the tip of the iceberg'", "firstAuthor": "Thompson", "multipleAuthors": true, "journal": "Colorectal Dis", "year": 2000, "design": "prospective-cohort", "n": 4006, "nField": "reported", "population": "adults over 16 in general practice who reported rectal bleeding", "intervention": "none (observational survey of symptoms)", "comparator": "", "primaryOutcome": "how often rectal bleeding is linked to colorectal cancer", "result": "only 1 in 709 people with rectal bleeding was later diagnosed with colorectal cancer", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this was a one-time mailed questionnaire with recall bias, no control group, and only one cancer case found, so it can't say much about any individual's cause.", "directness": "direct", "limitations": "Relies on self-reported symptoms via postal survey; only 1:4 who saw a GP were referred to hospital, so most cases were never medically confirmed.", "followUp": "5 years", "plainFinding": "Painless bleeding rarely means cancer.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23578119/", "sourceText": "OBJECTIVE: To determine the incidence of rectal bleeding and its predictive value for cancer in the general population, patient consultation rates to GPs, referral rates to hospital and the nature of rectal bleeding from benign causes. SUBJECTS AND METHODS: The study was based on a postal questionnaire in the setting of three General Practices in Portsmouth and South-east Hampshire (two in Portsmouth, one in Petersfield). There were 6000 subjects, over the age of 16 years, randomly selected from the three General Practices. The main outcome measures were incidence of rectal bleeding with respect to age and sex, the number who sought medical advice from their GPs and the numbers referred on to hospital. The frequency of dark red bleeding, of an associated change in bowel habit and the presence or absence of anal symptoms were also determined. The prevalence of colorectal cancer was determined in subjects reporting rectal bleeding in the 5-year period after the postal survey. RESULTS: Six thousand questionnaires were sent and 4006 (67%) were returned. Of the respondents 18% (709/4006) reported rectal bleeding in the previous year. Four percent (175/4006) had had bleeding for the first time and 38% (1522/4006) had bled at some time in the past. Of the 709 individuals, 512 (72%) had not consulted their GPs. Of the 197 (28%) who did, 50 (1:4, 7%) were referred to hospital. Eighteen percent (125/709) described the blood as dark red, and 88% (621/709) had anal symptoms. In 56% (394/709) the rectal bleeding was associated with a change in bowel habit mostly to hard stools (n=208), fewer to loose stools (n=98). Rectal cancer was diagnosed in only one patient 4 years after the first episode of rectal bleeding, giving a predictive value of rectal bleeding for colorectal cancer in the community of 1:709. CONCLUSION: Many people in the community have painless rectal bleeding, an associated change in bowel habit and dark red bleeding, factors previously thought to indicate a high risk of colorectal cancer. Rectal bleeding has however a low (1:709) predictive value for cancer. As the result of a considerable selection process, only a small number are investigated in hospital. These patients therefore represent a small proportion of all patients with this symptom. The value of the factors used to decide which patients need investigation should be re-assessed.", "provenance": [ { "field": "n", "quote": "Six thousand questionnaires were sent and 4006 (67%) were returned." }, { "field": "population", "quote": "6000 subjects, over the age of 16 years, randomly selected from the three General Practices" }, { "field": "intervention", "quote": "The study was based on a postal questionnaire" }, { "field": "primaryOutcome", "quote": "The prevalence of colorectal cancer was determined in subjects reporting rectal bleeding in the 5-year period after the postal survey." }, { "field": "result", "quote": "Rectal cancer was diagnosed in only one patient 4 years after the first episode of rectal bleeding, giving a predictive value of rectal bleeding for colorectal cancer in the community of 1:709." }, { "field": "followUp", "quote": "the 5-year period after the postal survey" } ] }, { "id": "pmid:10596577", "pmid": "10596577", "doi": null, "nctId": null, "pmcid": null, "title": "[Leiomyosarcoma of Meckel's diverticulum--a rare cause of acute hemorrhage in the lower part of the digestive system]", "firstAuthor": "Drobco", "multipleAuthors": false, "journal": "Rozhl Chir", "year": 1999, "design": "case-series", "n": 1, "nField": "reported", "population": "an adult male with sudden painless intestinal bleeding", "intervention": "not applicable - diagnostic case report", "comparator": "", "primaryOutcome": "cause of painless intestinal bleeding", "result": "bleeding was caused by a rare tumor (leiomyosarcoma) growing in Meckel's diverticulum, a pouch in the intestine", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show how common this cause is or what usually happens.", "directness": "direct", "limitations": "only one patient described; findings cannot be generalized to other cases of painless bleeding.", "followUp": "", "plainFinding": "Rare tumor caused painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/10596577/", "sourceText": "Meckel's diverticulum is a rare cause of haemorrhage into digestive tract in adults. A tumour arising in the diverticulum is also a rare cause of bleeding. Leiomyosarcomas represent 10-20% of malignant tumours in the small bowel and 1% of those located in the large bowel. These tumours have non-specific symptoms depending on their size, location and histology. Intestinal leiomyosarcomas may be the cause of surgical emergencies. We describe the case of an adult male with acute painless intestinal bleeding the cause of which was a leiomyosarcoma arising in Meckel's diverticulum. It was diagnosed during an acute operation. The main cause of the surgical emergency was an extremely rare complication of gastrointestinal leiomyosarcoma--intestinal bleeding.", "provenance": [ { "field": "population", "quote": "We describe the case of an adult male with acute painless intestinal bleeding the cause of which was a leiomyosarcoma arising in Meckel's diverticulum." }, { "field": "n", "quote": "We describe the case of an adult male with acute painless intestinal bleeding" }, { "field": "primaryOutcome", "quote": "We describe the case of an adult male with acute painless intestinal bleeding the cause of which was a leiomyosarcoma arising in Meckel's diverticulum." }, { "field": "result", "quote": "We describe the case of an adult male with acute painless intestinal bleeding the cause of which was a leiomyosarcoma arising in Meckel's diverticulum. It was diagnosed during an acute operation." }, { "field": "intervention", "quote": "It was diagnosed during an acute operation." } ] }, { "id": "pmid:10573430", "pmid": "10573430", "doi": "10.1016/s1055-8586(99)70027-2", "nctId": null, "pmcid": null, "title": "Gastrointestinal bleeding in infants and children: Meckel's diverticulum and intestinal duplication", "firstAuthor": "Brown", "multipleAuthors": true, "journal": "Semin Pediatr Surg", "year": 1999, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "infants and children with gastrointestinal bleeding", "intervention": "technetium 99m pertechnetate scanning and surgical resection", "comparator": "no comparator described", "primaryOutcome": "diagnosis and treatment of cause of bleeding", "result": "Meckel's diverticula and intestinal duplications cause painless, sometimes massive bleeding due to ectopic gastric mucosa, diagnosed by radionuclide scan and treated with surgical resection", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a narrative review describing typical causes and treatments rather than a study testing a specific outcome.", "directness": "direct", "limitations": "No original data, sample size, or comparative outcomes are reported; it is a descriptive review.", "followUp": "", "plainFinding": "Painless bleeding often from Meckel's diverticulum.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/10573430/", "sourceText": "Gastrointestinal bleeding in infants and children can be quite alarming and anxiety-provoking for parents and caregivers alike. In most cases the cause is benign, and the course self-limited. However, in the patient with significant bleeding, an aggressive diagnostic approach is warranted. The differential diagnosis can be extensive and varies depending on the age of the patient. Meckel's diverticula and intestinal duplications may cause gastrointestinal bleeding in almost any age group and require a high index of suspicion for diagnosis. Bleeding usually is painless but may be massive. The advent of technetium (Tc) 99m pertechnetate radionuclide scanning has greatly facilitated the diagnosis of Meckel's diverticula and may also be useful for intestinal duplications. A positive scan requires the presence of ectopic gastric mucosa, which may be identified in both Meckel's diverticula and intestinal duplications. The significance of ectopic gastric mucosa is that it contains acid-secreting parietal cells, which may cause ulceration and bleeding. Only rarely are intestinal duplications diagnosed preoperatively. After initial fluid resuscitation, bleeding from Meckel's diverticula and intestinal duplications require surgical intervention. Resection is the treatment of choice. Diverticulectomy or segmental bowel resection including the diverticulum should be performed for bleeding Meckel's diverticula. It is important to remove the ectopic mucosa and site of ulceration to prevent rebleeding episodes. Intestinal duplications share a common wall and blood supply with native bowel. Segmental resection is indicated if it can be performed without sacrificing a significant portion of bowel. A recent advance has been laparoscopic-assisted resection of Meckel's diverticula and intestinal duplication cysts. With the aid of the laparoscope, extracorporeal or intracorporeal resection may be performed.", "provenance": [ { "field": "population", "quote": "Gastrointestinal bleeding in infants and children can be quite alarming" }, { "field": "intervention", "quote": "The advent of technetium (Tc) 99m pertechnetate radionuclide scanning has greatly facilitated the diagnosis of Meckel's diverticula" }, { "field": "comparator", "quote": "Resection is the treatment of choice." }, { "field": "primaryOutcome", "quote": "require a high index of suspicion for diagnosis" }, { "field": "result", "quote": "Bleeding usually is painless but may be massive." }, { "field": "result", "quote": "The significance of ectopic gastric mucosa is that it contains acid-secreting parietal cells, which may cause ulceration and bleeding." } ] }, { "id": "pmid:9845644", "pmid": "9845644", "doi": "10.1159/000018665", "nctId": null, "pmcid": null, "title": "Diffuse cavernous hemangioma of the rectum and sigmoid colon", "firstAuthor": "Demircan", "multipleAuthors": true, "journal": "Dig Surg", "year": 1998, "design": "case-series", "n": 1, "nField": "reported", "population": "an 18-year-old man with painless rectal bleeding and hematuria due to diffuse cavernous hemangioma of the rectum and sigmoid colon", "intervention": "surgery removing the affected rectum and part of the bladder (low anterior resection and partial cystectomy)", "comparator": "", "primaryOutcome": "whether rectal bleeding stopped after surgery", "result": "no rectal bleeding occurred after surgery, but the patient died of a massive brain bleed 10 months later", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "this is a single patient case report, so it cannot show whether the treatment works in general.", "directness": "direct", "limitations": "only one patient described, no comparison group, and the cause of the later fatal brain bleed is not explained", "followUp": "10 months", "plainFinding": "Surgery stopped bleeding; patient later died of brain bleed.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/9845644/", "sourceText": "We present an 18-year-old man with painless rectal bleeding, hematuria and diffuse cavernous hemangioma of the rectum and sigmoid colon. Thirty units of blood were transfused during the interval preceding definitive surgery. Low anterior resection and partial cystectomy were performed. During the postoperative period no rectal bleeding occurred, but he died of massive intracerebral bleeding 10 months after the operation.", "provenance": [ { "field": "population", "quote": "an 18-year-old man with painless rectal bleeding, hematuria and diffuse cavernous hemangioma of the rectum and sigmoid colon" }, { "field": "n", "quote": "an 18-year-old man" }, { "field": "intervention", "quote": "Low anterior resection and partial cystectomy were performed." }, { "field": "result", "quote": "During the postoperative period no rectal bleeding occurred, but he died of massive intracerebral bleeding 10 months after the operation." }, { "field": "primaryOutcome", "quote": "During the postoperative period no rectal bleeding occurred" }, { "field": "followUp", "quote": "10 months after the operation" } ] }, { "id": "pmid:9260791", "pmid": "9260791", "doi": null, "nctId": null, "pmcid": null, "title": "Features associated with painless peptic ulcer bleeding", "firstAuthor": "Wilcox", "multipleAuthors": true, "journal": "Am J Gastroenterol", "year": 1997, "design": "prospective-cohort", "n": 449, "nField": "reported", "population": "patients hospitalized with upper GI bleeding caused by peptic ulcer", "intervention": "having a peptic ulcer causing bleeding", "comparator": "presence vs absence of abdominal pain in these patients", "primaryOutcome": "whether abdominal pain was present or absent alongside the bleeding", "result": "About 43% of patients with bleeding peptic ulcers had no abdominal pain; pain was linked to larger ulcer size, tobacco use, and age under 80", "resultDirection": "unclear", "quality": "moderate", "qualityWhy": "This was a reasonably large prospective study, but it only describes patterns of pain in ulcer bleeding rather than testing a treatment, so it can't say why any one person's bleeding occurs.", "directness": "direct", "limitations": "Observational description of symptoms only; relies on patient-reported history; excluded patients where history was unreliable or ulcer was malignant.", "followUp": "", "plainFinding": "Painless ulcer bleeding is common and normal.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/9260791/", "sourceText": "BACKGROUND: Painless peptic ulcer bleeding is well recognized, although clinical features associated with the absence of abdominal pain have received little attention. METHODS: Patients admitted for upper GI bleeding at a large inner-city hospital were questioned prospectively at the time of initial evaluation regarding the presence of any dyspepsia and/or abdominal pain, including nocturnal symptoms, within 1 wk of admission. A number of other clinical and endoscopic features were also recorded. The cause of upper GI bleeding was determined in most patients by endoscopy. Patients were excluded if a reliable history could not be obtained or if the ulcer was malignant. RESULTS: Over the 50-month study period, 449 patients with upper GI bleeding caused by peptic ulcer were evaluated, including 236 with gastric ulcer (53 prepyloric) and 213 with duodenal ulcer (28 with channel ulcer). Of these patients, abdominal pain was absent in 191 (43%; 95% confidence interval, 38-47%). There appeared to be no relationship of pain to race, gender, alcohol use, ulcer location, use and duration of nonsteroidal anti-inflammatory drugs, history of ulcer, or comorbidity. The only statistically significant correlates with abdominal pain were ulcer size (77% of patients with ulcers >2 cm reported pain as compared with 49% of patients with ulcers <1 cm; p < 0.001), tobacco use (p = 0.041), and age <80 yr (p = 0.02). CONCLUSIONS: Approximately half the patients with a bleeding peptic ulcer have no abdominal pain. Large ulcer size, use of tobacco, and age <80 yr seem to be the main determinants of ulcer-related pain in this setting.", "provenance": [ { "field": "population", "quote": "Patients admitted for upper GI bleeding at a large inner-city hospital" }, { "field": "n", "quote": "449 patients with upper GI bleeding caused by peptic ulcer were evaluated" }, { "field": "intervention", "quote": "Painless peptic ulcer bleeding is well recognized" }, { "field": "comparator", "quote": "abdominal pain was absent in 191 (43%; 95% confidence interval, 38-47%)" }, { "field": "primaryOutcome", "quote": "questioned prospectively at the time of initial evaluation regarding the presence of any dyspepsia and/or abdominal pain" }, { "field": "result", "quote": "The only statistically significant correlates with abdominal pain were ulcer size (77% of patients with ulcers >2 cm reported pain as compared with 49% of patients with ulcers <1 cm; p < 0.001), tobacco use (p = 0.041), and age <80 yr (p = 0.02)" } ] }, { "id": "pmid:9036893", "pmid": "9036893", "doi": null, "nctId": null, "pmcid": null, "title": "Hemangiopericytoma: an unusual cause of upper gastrointestinal hemorrhage", "firstAuthor": "Grimsley", "multipleAuthors": true, "journal": "Am Surg", "year": 1997, "design": "case-series", "n": 1, "nField": "reported", "population": "A patient with repeated severe bleeding from the upper digestive tract", "intervention": "None (diagnostic case report)", "comparator": "None", "primaryOutcome": "Cause of the bleeding and how it was diagnosed", "result": "A rare tumor (hemangiopericytoma) near the spleen caused increased blood vessels and erosions in the stomach wall leading to bleeding, without the tumor directly invading the stomach", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how common or typical this cause is.", "directness": "indirect", "limitations": "Single case; no comparison group; findings may not generalize to other causes of painless rectal or GI bleeding.", "followUp": "", "plainFinding": "Rare tumor caused hidden stomach bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/9036893/", "sourceText": "Hemangiopericytomas, first described in 1942, are rare, highly vascular neoplasms that arise from capillary pericytes. They are seen most commonly as a painless mass arising from the lower extremity but can also originate in the pelvic retroperitoneum and on the head, neck, chest, and abdomen. An unusual case is reported here of a patient presenting with recurrent massive upper gastrointestinal (GI) bleeding in whom a large hemangiopericytoma was found arising in the perisplenic soft tissues. Precedence exists in the literature for the association of hemangiopericytoma with GI bleeding. In prior reports, however, a mural origin of the tumor and subsequent bleeding into the GI lumen was demonstrated. In the case presented here, marked dilatation of the gastric and splenic vessels was noted, but there was no direct pathologic involvement of the stomach wall. It is proposed that superficial gastric erosions combined with the tumor-associated increased vascularity within the stomach wall led to recurrent major bleeding. Diagnosis of these tumors roentgenographically is nonspecific, but angiography is helpful. Morphological characteristics allow accurate histopathological diagnosis and provide prognostic information. The treatment of choice remains wide surgical excision, with the addition of radiation or chemotherapy in selected cases.", "provenance": [ { "field": "n", "quote": "An unusual case is reported here of a patient presenting with recurrent massive upper gastrointestinal (GI) bleeding" }, { "field": "population", "quote": "a patient presenting with recurrent massive upper gastrointestinal (GI) bleeding" }, { "field": "intervention", "quote": "Diagnosis of these tumors roentgenographically is nonspecific, but angiography is helpful." }, { "field": "comparator", "quote": "In prior reports, however, a mural origin of the tumor and subsequent bleeding into the GI lumen was demonstrated." }, { "field": "primaryOutcome", "quote": "It is proposed that superficial gastric erosions combined with the tumor-associated increased vascularity within the stomach wall led to recurrent major bleeding." }, { "field": "result", "quote": "marked dilatation of the gastric and splenic vessels was noted, but there was no direct pathologic involvement of the stomach wall" } ] }, { "id": "pmid:8962763", "pmid": "8962763", "doi": null, "nctId": null, "pmcid": null, "title": "[Options in the surgical treatment of diffuse cavernous hemangioma of the rectum]", "firstAuthor": "Castellví", "multipleAuthors": true, "journal": "Rev Esp Enferm Dig", "year": 1996, "design": "case-series", "n": 1, "nField": "reported", "population": "a 17-year-old patient with cavernous hemangioma of the rectum causing painless rectal bleeding", "intervention": "conservative proctectomy with colo-anal anastomosis", "comparator": "colo-anal sleeve anastomosis with large rectal mucosectomy, or abdominoperineal resection", "primaryOutcome": "surgical management of the rectal hemangioma while avoiding abdominoperineal resection", "result": "the abstract describes the surgical options and recommends conservative proctectomy with colo-anal anastomosis when other pelvic organs are not affected, as determined by MRI", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single case report describing one patient's surgery, so it cannot show how well the treatment generally works.", "directness": "direct", "limitations": "only one patient described; no outcome data such as recurrence, complications, or recovery reported.", "followUp": "", "plainFinding": "Surgery described for rectal hemangioma bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/8962763/", "sourceText": "Cavernous haemangioma of the rectum is an unusual hamartomatous malformation. Patients usually present with painless massive rectal bleeding that generally begins at an early age and frequently surgery is necessary. To avoid abdominoperineal resection of the rectum in these patients, a procedure of colo-anal sleeve anastomosis, that includes a large rectal mucosectomy, has been described. However, in our opinion, if affectation of other pelvic organs can been excluded by MRI, it is easier to do a conservative proctectomy with colo-anal anastomosis. We present a case in a seventeen years old patient.", "provenance": [ { "field": "population", "quote": "We present a case in a seventeen years old patient." }, { "field": "population", "quote": "Patients usually present with painless massive rectal bleeding that generally begins at an early age" }, { "field": "intervention", "quote": "it is easier to do a conservative proctectomy with colo-anal anastomosis" }, { "field": "comparator", "quote": "a procedure of colo-anal sleeve anastomosis, that includes a large rectal mucosectomy, has been described" }, { "field": "comparator", "quote": "To avoid abdominoperineal resection of the rectum in these patients" }, { "field": "primaryOutcome", "quote": "To avoid abdominoperineal resection of the rectum in these patients, a procedure of colo-anal sleeve anastomosis, that includes a large rectal mucosectomy, has been described." }, { "field": "result", "quote": "if affectation of other pelvic organs can been excluded by MRI, it is easier to do a conservative proctectomy with colo-anal anastomosis" }, { "field": "n", "quote": "We present a case in a seventeen years old patient." } ] }, { "id": "pmid:1481551", "pmid": "1481551", "doi": null, "nctId": null, "pmcid": null, "title": "[Proctoscopic Doppler ultrasound in diagnosis and therapy of symptomatic first degree hemorrhoids ]", "firstAuthor": "Jaspersen", "multipleAuthors": true, "journal": "Z Gastroenterol", "year": 1992, "design": "rct", "n": 124, "nField": "reported", "population": "patients with first degree hemorrhoids causing painless rectal bleeding", "intervention": "Doppler ultrasound-guided sclerotherapy injection for hemorrhoids", "comparator": "standard sclerotherapy injection without Doppler guidance", "primaryOutcome": "complete elimination of hemorrhoids and arterial blood flow at 2-week follow-up", "result": "87% cured with Doppler-guided treatment versus 37% cured without Doppler guidance", "resultDirection": "benefit", "quality": "low", "qualityWhy": "Although randomized and controlled, this is a small, old study without detail on blinding or long-term outcomes, and it addresses treatment of hemorrhoids rather than the broader question of why bleeding occurs.", "directness": "indirect", "limitations": "Abstract does not report blinding, long-term follow-up beyond 2 weeks, or how randomization was performed.", "followUp": "2 weeks", "plainFinding": "Doppler-guided injection cured hemorrhoids better.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/1481551/", "sourceText": "Within the framework of a prospective study two comparable collectives with each 62 patients and symptomatic first grade hemorrhoidal disease were examined. Guiding symptom was painless hematochezia. The hemorrhoids of collective A were evaluated with the aid of transproctoscopic Doppler ultrasound. The depth of the vessels was determined and a Doppler located injection therapy was performed. The patients of collective B were only investigated by means of proctoscopy and sclerosed without Doppler. Sclerosing injection was carried out in all cases with 6 ml Phenylamygdalic oil by 3, 7 and 11 o'clock lithotomy position. Success of therapy was controlled in all patients 2 weeks later Doppler sonographically. In 87% of the Doppler controlled treated patients the hemorrhoids were completely eliminated and no more arterial blood flow could be scanned. On the contrary only 37% of the initially not Doppler scanned patients were cured. Endoscopic Doppler ultrasound is and effective method in evaluation and treatment of symptomatic first grade hemorrhoids.", "provenance": [ { "field": "population", "quote": "two comparable collectives with each 62 patients and symptomatic first grade hemorrhoidal disease were examined. Guiding symptom was painless hematochezia." }, { "field": "intervention", "quote": "The hemorrhoids of collective A were evaluated with the aid of transproctoscopic Doppler ultrasound." }, { "field": "comparator", "quote": "The patients of collective B were only investigated by means of proctoscopy and sclerosed without Doppler." }, { "field": "primaryOutcome", "quote": "Success of therapy was controlled in all patients 2 weeks later Doppler sonographically" }, { "field": "result", "quote": "In 87% of the Doppler controlled treated patients the hemorrhoids were completely eliminated and no more arterial blood flow could be scanned. On the contrary only 37% of the initially not Doppler scanned patients were cured." }, { "field": "n", "quote": "two comparable collectives with each 62 patients" } ] }, { "id": "pmid:1402312", "pmid": "1402312", "doi": "10.1007/BF00360355", "nctId": null, "pmcid": null, "title": "Primary adenosquamous and squamous cell carcinoma of the colon and rectum", "firstAuthor": "Schneider", "multipleAuthors": true, "journal": "Int J Colorectal Dis", "year": 1992, "design": "case-series", "n": 3, "nField": "reported", "population": "patients with squamous cell or adenosquamous carcinoma of the rectum", "intervention": "surgical removal of the tumor, with chemoradiation therapy afterward in two patients", "comparator": "no comparison group", "primaryOutcome": "presenting symptoms and tumor characteristics", "result": "all three patients presented with painless rectal bleeding; tumors were treated with surgery, and two also had chemoradiation", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a report of just three cases with no comparison group, so it cannot show whether any treatment works, only that this rare cancer can cause painless bleeding", "directness": "direct", "limitations": "only three cases reported, no control group, and no outcome data on survival or recurrence given in the abstract", "followUp": "", "plainFinding": "Rare rectal cancer causes painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/1402312/", "sourceText": "Three new cases of squamous cell and adenosquamous carcinoma of the rectum are reported, bringing the total number of cases in the English medical literature to 72. Each of the three patients presented with painless hematochezia. Therapy was by surgical resection followed by chemoradiation therapy in two patients. The incidence, presentation, diagnostic criteria and methods, tumor location, natural history, theory of etiology and management of this unusual tumor are discussed.", "provenance": [ { "field": "n", "quote": "Three new cases of squamous cell and adenosquamous carcinoma of the rectum are reported" }, { "field": "population", "quote": "squamous cell and adenosquamous carcinoma of the rectum" }, { "field": "intervention", "quote": "Therapy was by surgical resection followed by chemoradiation therapy in two patients." }, { "field": "comparator", "quote": "Three new cases of squamous cell and adenosquamous carcinoma of the rectum are reported, bringing the total number of cases in the English medical literature to 72." }, { "field": "primaryOutcome", "quote": "Each of the three patients presented with painless hematochezia." }, { "field": "result", "quote": "Each of the three patients presented with painless hematochezia. Therapy was by surgical resection followed by chemoradiation therapy in two patients." } ] }, { "id": "pmid:1485388", "pmid": "1485388", "doi": null, "nctId": null, "pmcid": null, "title": "Duplication of the rectum resembling a juvenile polyp", "firstAuthor": "Kizilcan", "multipleAuthors": true, "journal": "Turk J Pediatr", "year": 1992, "design": "case-series", "n": 1, "nField": "reported", "population": "a five-year-old boy with painless rectal bleeding and a rectal mass", "intervention": "not applicable - case report describing diagnosis", "comparator": "none", "primaryOutcome": "diagnosis of the cause of painless rectal bleeding and rectal mass", "result": "the rectal mass, initially thought to be a polyp, was actually a cystic duplication of the rectum", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a single case report, so it cannot show how common this cause is or how it compares to other causes.", "directness": "direct", "limitations": "only one patient described, no comparison group, and no information on treatment outcome.", "followUp": "", "plainFinding": "Rare cause: rectal duplication cyst.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/1485388/", "sourceText": "A five-year-old boy with a rectal mass mimicking a rectal polyp, which proved to be a cystic duplication of the rectum, is presented. In a child with painless rectal bleeding, a mass palpated during rectal examination is usually diagnosed initially as being a rectal polyp. However, the case presented revealed the possibility of rectal duplication.", "provenance": [ { "field": "population", "quote": "A five-year-old boy with a rectal mass mimicking a rectal polyp" }, { "field": "primaryOutcome", "quote": "In a child with painless rectal bleeding, a mass palpated during rectal examination is usually diagnosed initially as being a rectal polyp." }, { "field": "result", "quote": "which proved to be a cystic duplication of the rectum" }, { "field": "n", "quote": "A five-year-old boy" }, { "field": "intervention", "quote": "a rectal mass mimicking a rectal polyp, which proved to be a cystic duplication of the rectum, is presented" }, { "field": "comparator", "quote": "the case presented revealed the possibility of rectal duplication" } ] }, { "id": "pmid:1356474", "pmid": "1356474", "doi": null, "nctId": null, "pmcid": null, "title": "Rectal leiomyosarcoma: acute presentation after local injury", "firstAuthor": "Vandoni", "multipleAuthors": true, "journal": "Eur J Surg", "year": 1992, "design": "case-series", "n": 1, "nField": "reported", "population": "66-year-old woman with no symptoms before a fall", "intervention": "surgical removal of rectum (abdominoperineal excision)", "comparator": "none", "primaryOutcome": "diagnosis and recurrence after surgery", "result": "Surgery removed a rare rectal tumor (leiomyosarcoma); no recurrence after 4 years", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show what usually causes or treats painless rectal bleeding.", "directness": "indirect", "limitations": "Only one patient, no comparison group, and findings may not generalize.", "followUp": "4 years", "plainFinding": "Rare tumor found and removed successfully.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/1356474/", "sourceText": "Rectal leiomyosarcoma is rare, often large and found in the distal third of the rectum. Most symptoms differ from those of an adenocarcinoma. Staging is difficult and should include tumour size, necrosis, cellularity, number of mitoses and anaplasia. Abdominoperineal excision (APE) remains the only effective treatment. A 66 year old asymptomatic female presented with painless rectal bleeding after a fall. Digital examination and proctoscopy revealed a mass on the posterior rectal wall. Pelvic ultrasonography, arteriography and CT-Scan showed a huge retro-rectal lesion. Following APE, histopathology confirmed a leiomyosarcoma. No adjuvant therapy was given; there is no recurrence 4 years later.", "provenance": [ { "field": "n", "quote": "A 66 year old asymptomatic female presented with painless rectal bleeding after a fall." }, { "field": "population", "quote": "A 66 year old asymptomatic female presented with painless rectal bleeding after a fall." }, { "field": "intervention", "quote": "Abdominoperineal excision (APE) remains the only effective treatment." }, { "field": "comparator", "quote": "No adjuvant therapy was given; there is no recurrence 4 years later." }, { "field": "primaryOutcome", "quote": "Following APE, histopathology confirmed a leiomyosarcoma." }, { "field": "result", "quote": "No adjuvant therapy was given; there is no recurrence 4 years later." } ] }, { "id": "pmid:1798351", "pmid": "1798351", "doi": null, "nctId": null, "pmcid": null, "title": "[Proctoscopic Doppler sonography in hemorrhoidal hemorrhage--vascular diagnosis and therapy follow-up]", "firstAuthor": "Jaspersen", "multipleAuthors": false, "journal": "Leber Magen Darm", "year": 1991, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with first or second degree hemorrhoids causing painless bright red rectal bleeding", "intervention": "20 MHz microvascular Doppler sonography used with proctoscopy to look at the blood vessels and check treatment results", "comparator": "", "primaryOutcome": "ability to image the arterial blood supply of hemorrhoids and confirm whether sclerosing injection therapy worked", "result": "the abstract states that arterial blood supply can be reliably imaged and that therapy success can be verified and documented after injecting a sclerosing substance", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a descriptive report about a diagnostic imaging technique, not a study comparing treatments or outcomes in a defined group of patients.", "directness": "indirect", "limitations": "no patient numbers, no comparison group, and no quantified outcome data are given in the abstract", "followUp": "", "plainFinding": "Describes a hemorrhoid imaging test.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/1798351/", "sourceText": "Painless bright red peranal bleeding is a leading symptom of first and second degree hemorrhoid. After having excluded the possibility of bleeding in an upper region diagnosis is made proctoscopically, which is generally followed by injection therapy. Arterial blood supply can be reliably imaged with the aid of 20 MHz microvascular Doppler sonography and the success of therapy can be verified as well as documented after injecting a sclerosing substance.", "provenance": [ { "field": "population", "quote": "Painless bright red peranal bleeding is a leading symptom of first and second degree hemorrhoid." }, { "field": "intervention", "quote": "Arterial blood supply can be reliably imaged with the aid of 20 MHz microvascular Doppler sonography" }, { "field": "primaryOutcome", "quote": "the success of therapy can be verified as well as documented after injecting a sclerosing substance" }, { "field": "result", "quote": "Arterial blood supply can be reliably imaged with the aid of 20 MHz microvascular Doppler sonography and the success of therapy can be verified as well as documented after injecting a sclerosing substance." } ] }, { "id": "pmid:1812259", "pmid": "1812259", "doi": "10.1016/0022-3468(91)90601-o", "nctId": null, "pmcid": null, "title": "Meckel's diverticulum in children: a 20-year review", "firstAuthor": "St-Vil", "multipleAuthors": true, "journal": "J Pediatr Surg", "year": 1991, "design": "case-series", "n": 164, "nField": "reported", "population": "children who had a Meckel's diverticulum found during abdominal surgery", "intervention": "surgical removal (resection) of Meckel's diverticulum, studied over 20 years", "comparator": "", "primaryOutcome": "how patients with Meckel's diverticulum presented, including rectal bleeding", "result": "Of 117 symptomatic patients, 45 (38%) had severe painless rectal bleeding, and 67% of those needed a blood transfusion; a nuclear medicine scan correctly found the diverticulum in 85% of those tested", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This is a retrospective review of past surgical cases without a comparison group, so it describes patterns but cannot prove cause and effect.", "directness": "direct", "limitations": "Retrospective design, abstract truncated, no control group, relies on surgical records from 1970-1989.", "followUp": "", "plainFinding": "Painless rectal bleeding from Meckel's diverticulum.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/1812259/", "sourceText": "Meckel's diverticulum occurs in 2% of the population and may present at any age. Its management, when found incidentally at laparotomy, remains controversial, particularly in the pediatric population. From 1970 to 1989, a Meckel's diverticulum was discovered in 164 children at laparotomy. There were 120 boys and 44 girls with a mean age of 5.2 years (range, 0 to 18 years). Forty-seven cases were asymptomatic, representing an incidental finding at laparotomy, 25 were resected, and ectopic gastric mucosa was present in 7 specimens (28%). Three postoperative deaths (6%) that were not related to the resection and 2 complications (4%) (postoperative leak and wound infection) occurred in this group. Of the 117 symptomatic patients, 49 (42%) presented with bowel obstruction, 45 (38%) had rectal bleeding, 16 (14%) had diverticulitis, and 7 (6%) had umbilical pathology. Volvulus (20) and intussusception (19) were the most common causes of obstruction. Predisposing factors for bowel obstruction were fibrous bands to umbilicus or mesentery (37%) and ectopic mucosa (35%). Severe painless rectal bleeding occurred in 45 patients, 30 of whom (67%) required blood transfusion. A nuclear medicine Meckel scan was positive in 32 of 37 patients (85%). Contrast studies were not diagnostic; colonoscopy and gastroscopy ruled out other causes of bleeding. Patients with diverticulitis (16) presented with acute abdominal pain compatible with appendicitis. In the symptomatic group, ectopic mucosa was present in 61% of the resected specimens. Gastric (88%), pancreatic (7%), and gastric with pancreatic (3%) were the most common ectopic tissue. Postoperative morbidity and mortality for symptomatic patients was 8.5% and 0%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)", "provenance": [ { "field": "n", "quote": "a Meckel's diverticulum was discovered in 164 children at laparotomy" }, { "field": "population", "quote": "Meckel's diverticulum occurs in 2% of the population and may present at any age" }, { "field": "intervention", "quote": "25 were resected" }, { "field": "primaryOutcome", "quote": "45 (38%) had rectal bleeding" }, { "field": "result", "quote": "Severe painless rectal bleeding occurred in 45 patients, 30 of whom (67%) required blood transfusion. A nuclear medicine Meckel scan was positive in 32 of 37 patients (85%)." } ] }, { "id": "pmid:2225816", "pmid": "2225816", "doi": null, "nctId": null, "pmcid": null, "title": "Colocolic intussusception in a three-year-old child caused by a colonic polyp", "firstAuthor": "Arthur", "multipleAuthors": true, "journal": "Conn Med", "year": 1990, "design": "case-series", "n": 1, "nField": "reported", "population": "a three-year-old child with colocolic intussusception caused by a colonic polyp", "intervention": "Colonoscopic polypectomy performed by an experienced endoscopist", "comparator": "surgical removal of the polyp", "primaryOutcome": "cause of painless rectal bleeding (hematochezia) in children", "result": "Juvenile colonic polyps were identified as the cause of painless hematochezia and, when large, could act as a lead point for intussusception", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single case report of one child, so it cannot show how common or reliable this cause of bleeding is.", "directness": "direct", "limitations": "Only one patient reported, no control group, and findings based on a single case plus literature review.", "followUp": "", "plainFinding": "Painless bleeding caused by colon polyp.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/2225816/", "sourceText": "Colocolic intussusception is an uncommon cause of pediatric intestinal obstruction in North America; 95% of cases are ileocolic in location, with an equal percentage in which no pathologic lead point is evident on barium enema or laparotomy. In the last 20 years less than 3% of approximately 32,500 reported cases of intussusception originated in the colon. In a significant number of these cases juvenile polyps were identified as leading points. The majority of juvenile polyps occur in the rectosigmoid colon within the reach of a standard pediatric sigmoidoscope. These tumors most often cause painless hematochezia. Occasionally, juvenile polyps may grow large and serve as lead points for colocolic intussusception when located in the proximal colon. Pediatric patients presenting with documented colocolic intussusception should suggest the possibility of a colonic polyp or other mass lesion. Careful physical examination and barium studies should provide important diagnostic clues. Treatment is aimed at removing the lead point in patients presenting with intestinal obstruction. Colonoscopic polypectomy performed by an experienced endoscopist may serve as an alternative to surgical removal of the polyp. We report a case in a three-old-child of colocolic intussusception caused by a colonic polyp, and review some of the salient features of this clinical entity.", "provenance": [ { "field": "n", "quote": "a three-old-child" }, { "field": "population", "quote": "We report a case in a three-old-child of colocolic intussusception caused by a colonic polyp" }, { "field": "intervention", "quote": "Colonoscopic polypectomy performed by an experienced endoscopist may serve as an alternative to surgical removal of the polyp." }, { "field": "comparator", "quote": "Colonoscopic polypectomy performed by an experienced endoscopist may serve as an alternative to surgical removal of the polyp." }, { "field": "primaryOutcome", "quote": "These tumors most often cause painless hematochezia." }, { "field": "result", "quote": "In a significant number of these cases juvenile polyps were identified as leading points." } ] }, { "id": "pmid:2771480", "pmid": "2771480", "doi": "10.1007/BF02387639", "nctId": null, "pmcid": null, "title": "Computerized tomography appearances of pelvic haemangioma involving the large bowel in childhood", "firstAuthor": "Yeoman", "multipleAuthors": true, "journal": "Pediatr Radiol", "year": 1989, "design": "case-series", "n": 2, "nField": "reported", "population": "children with painless rectal bleeding, one with Vater association and one with Klippel-Trenaunay syndrome", "intervention": "CT scan to diagnose pelvic haemangioma", "comparator": "plain abdominal X-ray", "primaryOutcome": "ability to diagnose the cause of painless rectal bleeding", "result": "CT identified a pelvic haemangioma involving the rectum as the cause of bleeding in both children", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "Only two cases described, so this cannot show how common this cause is or how reliable CT is in general.", "directness": "indirect", "limitations": "Extremely small case series (two children) with specific underlying syndromes, not a general study of rectal bleeding causes.", "followUp": "", "plainFinding": "Rare blood vessel growth found as cause.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/2771480/", "sourceText": "The Computed Tomography (CT) appearance of a pelvic haemangioma involving the rectum in two children, one with the Vater association and one with Klippel-Trenaunay syndrome, is described. Both cases complained of painless rectal bleeding and the diagnosis was suggested by the presence of pelvic phleboliths on the plain abdominal radiograph. CT provides a simple, non-invasive method of diagnosing such lesions and assessing their extent.", "provenance": [ { "field": "n", "quote": "pelvic haemangioma involving the rectum in two children" }, { "field": "population", "quote": "Both cases complained of painless rectal bleeding" }, { "field": "intervention", "quote": "The Computed Tomography (CT) appearance of a pelvic haemangioma involving the rectum in two children" }, { "field": "comparator", "quote": "the diagnosis was suggested by the presence of pelvic phleboliths on the plain abdominal radiograph" }, { "field": "primaryOutcome", "quote": "CT provides a simple, non-invasive method of diagnosing such lesions and assessing their extent." }, { "field": "result", "quote": "the diagnosis was suggested by the presence of pelvic phleboliths on the plain abdominal radiograph. CT provides a simple, non-invasive method of diagnosing such lesions and assessing their extent." } ] }, { "id": "pmid:6608875", "pmid": "6608875", "doi": null, "nctId": null, "pmcid": null, "title": "Isolated gastric varices due to spontaneous splenic vein thrombosis", "firstAuthor": "Goldberg", "multipleAuthors": true, "journal": "Am J Gastroenterol", "year": 1984, "design": "case-series", "n": null, "nField": "not-reported", "population": "a patient with unexplained, painless recurrent gastrointestinal bleeding and an enlarged spleen", "intervention": "diagnostic workup (barium contrast, endoscopy, arteriography) leading to splenectomy", "comparator": "none", "primaryOutcome": "finding the cause of painless recurrent bleeding", "result": "bleeding was caused by gastric varices from a blood clot in the splenic vein, treated by removing the spleen", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a single patient case report, so it cannot show how often this cause applies to others.", "directness": "direct", "limitations": "Only one patient described; no comparison group; findings may not generalize.", "followUp": "", "plainFinding": "Rare clot caused painless bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/6608875/", "sourceText": "Isolated bleeding gastric varices due to a spontaneous idiopathic thrombosis of the splenic vein was found to be the cause of obscure, painless recurrent bleeding in our patient. The diagnosis of spontaneous splenic vein thrombosis should be considered in the presence of gastrointestinal bleeding with unexplained splenomegaly. Prominent gastric folds may be the only barium contrast or endoscopic finding often lacking esophageal varices. Arteriography is essential in demonstrating an obstructed splenic vein. Splenectomy is the treatment of choice of \"left-sided\" portal hypertension.", "provenance": [ { "field": "population", "quote": "obscure, painless recurrent bleeding in our patient" }, { "field": "intervention", "quote": "Arteriography is essential in demonstrating an obstructed splenic vein. Splenectomy is the treatment of choice" }, { "field": "comparator", "quote": "Isolated bleeding gastric varices due to a spontaneous idiopathic thrombosis of the splenic vein was found to be the cause of obscure, painless recurrent bleeding in our patient." }, { "field": "primaryOutcome", "quote": "was found to be the cause of obscure, painless recurrent bleeding in our patient" }, { "field": "result", "quote": "Isolated bleeding gastric varices due to a spontaneous idiopathic thrombosis of the splenic vein was found to be the cause of obscure, painless recurrent bleeding in our patient." } ] }, { "id": "pmid:6606026", "pmid": "6606026", "doi": "10.1097/00005176-198311000-00017", "nctId": null, "pmcid": null, "title": "Sigmoidoscopy, colonoscopy, and radiology in the evaluation of children with rectal bleeding", "firstAuthor": "Cucchiara", "multipleAuthors": true, "journal": "J Pediatr Gastroenterol Nutr", "year": 1983, "design": "case-series", "n": 103, "nField": "reported", "population": "children with rectal bleeding, average age about 3.5 years", "intervention": "visual exam of anus, sigmoidoscopy with biopsy, colonoscopy, and contrast X-ray of the colon", "comparator": "no separate comparator group; different diagnostic tests compared against each other", "primaryOutcome": "whether a cause of the rectal bleeding could be found", "result": "most cases were diagnosed with exam and sigmoidoscopy, further tests found the cause in almost all the rest, but 6 children with mild painless bleeding stayed undiagnosed", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a small, uncontrolled case series describing diagnostic tests rather than a comparative study of treatment or outcomes.", "directness": "indirect", "limitations": "only looked at children, no control group, and did not explain what caused the bleeding in a small subset of cases", "followUp": "", "plainFinding": "Painless bleeding sometimes stays unexplained.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/6606026/", "sourceText": "The authors evaluated the diagnostic role of sigmoidoscopy, colonoscopy, and double contrast radiology in 103 children with rectal bleeding, with or without other gastrointestinal symptoms. The children's mean age was 44 months, with a range from 1 month to 12 years. In 74.5% of the subjects investigated, visual inspection of the anus and sigmoidoscopy with rectal biopsy disclosed a positive diagnosis. Of the remaining patients, a conclusive diagnosis was reached by either colonoscopy or double contrast radiology in all but six patients. These six, with mild painless hematochezia, remained without a diagnosis. The diagnostic procedure in pediatric patients with rectal bleeding should include an initial visual inspection of the anus, and sigmoidoscopy; air contrast enema and colonoscopy should be performed only in children whose sigmoidoscopy is negative, in diagnostic assessment of inflammatory bowel disease, and in cases of recurrent bleeding after removal of rectal polyps. Colonoscopy is important also in the follow-up examination of children with inflammatory bowel disease and allows the removal of polyps located in the proximal colon.", "provenance": [ { "field": "n", "quote": "103 children with rectal bleeding" }, { "field": "population", "quote": "The children's mean age was 44 months, with a range from 1 month to 12 years." }, { "field": "intervention", "quote": "the diagnostic role of sigmoidoscopy, colonoscopy, and double contrast radiology" }, { "field": "comparator", "quote": "sigmoidoscopy, colonoscopy, and double contrast radiology in 103 children with rectal bleeding" }, { "field": "primaryOutcome", "quote": "a positive diagnosis" }, { "field": "result", "quote": "In 74.5% of the subjects investigated, visual inspection of the anus and sigmoidoscopy with rectal biopsy disclosed a positive diagnosis. Of the remaining patients, a conclusive diagnosis was reached by either colonoscopy or double contrast radiology in all but six patients. These six, with mild painless hematochezia, remained without a diagnosis." } ] }, { "id": "pmid:7277147", "pmid": "7277147", "doi": "10.1016/s0022-3468(81)80015-2", "nctId": null, "pmcid": null, "title": "The role of sigmoidoscopy, radiographs, and colonoscopy in the diagnostic evaluation of pediatric age patients with suspected juvenile polyps", "firstAuthor": "Euler", "multipleAuthors": true, "journal": "J Pediatr Surg", "year": 1981, "design": "case-series", "n": 43, "nField": "reported", "population": "children with painless rectal bleeding, likely due to juvenile polyps", "intervention": "diagnostic exams: rigid sigmoidoscopy, barium enema x-ray, and colonoscopy", "comparator": "different diagnostic tests compared to each other", "primaryOutcome": "finding and removing polyps in the colon", "result": "sigmoidoscopy found and removed polyps in 31 of 43 children; barium enema found more polyps further up in only 4 of those 31, but in 7 of 12 children whose sigmoidoscopy was negative; colonoscopy found further polyps in 8 of 11 children who had polyps removed", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a small, retrospective look at test results in 43 children with no control group, so it shows how testing was used rather than proving one approach is better.", "directness": "direct", "limitations": "small number of patients, no comparison group, retrospective description of diagnostic practice", "followUp": "", "plainFinding": "Painless bleeding usually caused by benign polyps.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/7277147/", "sourceText": "Juvenile polyps are the most common cause of painless hematochezia in pediatric Age patients after the first year of life. This study evaluated the role of rigid proctosigmoidoscopy, air contrast barium enema examinations, and colonoscopy in the diagnostic approach to 43 such patients. During sigmoidoscopy, polyps were removed from 31 children. On subsequent barium enema examination, more proximal lesions were found in only 4 of these 31 patients, but were seen in 7 of the 12 children who had negative sigmoidoscopic evaluations. Fourteen children had colonoscopy performed. This group included the latter 12 patients plus 2 of the former 4 who again developed hematochezia. Polypectomies were done during 11 of these procedures. Eight of these 11 children had proximal lesions seen during radiographic studies. The diagnostic approach to pediatric age patients with painless hematochezia should include an initial rigid sigmoidoscopic examination. Barium enema evaluation should be reserved for those patients requiring colonoscopy. The latter examination should be performed in all children who have had negative sigmoidoscopic examinations plus those who have had polyps removed from the rectum and then again develop hematochezia.", "provenance": [ { "field": "population", "quote": "Juvenile polyps are the most common cause of painless hematochezia in pediatric Age patients after the first year of life." }, { "field": "intervention", "quote": "This study evaluated the role of rigid proctosigmoidoscopy, air contrast barium enema examinations, and colonoscopy in the diagnostic approach to 43 such patients." }, { "field": "comparator", "quote": "This study evaluated the role of rigid proctosigmoidoscopy, air contrast barium enema examinations, and colonoscopy in the diagnostic approach to 43 such patients." }, { "field": "primaryOutcome", "quote": "During sigmoidoscopy, polyps were removed from 31 children." }, { "field": "result", "quote": "During sigmoidoscopy, polyps were removed from 31 children. On subsequent barium enema examination, more proximal lesions were found in only 4 of these 31 patients, but were seen in 7 of the 12 children who had negative sigmoidoscopic evaluations." }, { "field": "result", "quote": "Eight of these 11 children had proximal lesions seen during radiographic studies." }, { "field": "n", "quote": "43 such patients" } ] }, { "id": "pmid:6968608", "pmid": "6968608", "doi": "10.1002/bjs.1800671108", "nctId": null, "pmcid": null, "title": "Comparison of rubber band ligation and haemorrhoidectomy for second- and third-degree haemorrhoids: a prospective clinical trial", "firstAuthor": "Murie", "multipleAuthors": true, "journal": "Br J Surg", "year": 1980, "design": "rct", "n": 100, "nField": "reported", "population": "adults with second- or third-degree prolapsing hemorrhoids", "intervention": "rubber band ligation (outpatient procedure)", "comparator": "surgical hemorrhoidectomy", "primaryOutcome": "relief of hemorrhoid symptoms (bleeding and prolapse) at one year", "result": "Surgery relieved more patients' symptoms than banding (44 of 45 vs 34 of 43, P<0.05), but banding caused less pain and much less time off work (3 days vs 32 days, P<0.001)", "resultDirection": "mixed", "quality": "moderate", "qualityWhy": "It was a randomized trial comparing two treatments, but it was small, old, and some patients were lost to follow-up by one year.", "directness": "indirect", "limitations": "Not all patients were reassessed at one year; no untreated or placebo comparison group; study is from 1980 and may not reflect modern practice.", "followUp": "One year", "plainFinding": "Surgery worked better but hurt more.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/6968608/", "sourceText": "One hundred patients with second- or third-degree haemorrhoids were randomly allocated to haemorrhoidectomy (50) or rubber band ligation (50). Forty-two in each group presented with rectal bleeding; haemorrhoidectomy relieved 36 and rubber band ligation relieved 31 of this symptom. All patients had prolapsing haemorrhoids at presentation. One year after treatment 45 haemorrhoidectomy and 43 rubber band ligation patients were assessed. Haemorrhoidectomy relieved 44 of 45 patients and rubber band ligation relieved 34 of 43 (P < 0.05). Haemorrhoidectomy caused pain in all cases, lasting for more than 48 h in 35. Rubber band ligation was painless in 5 and produced pain for more than 48 h in 15. Mean time off work was 32 days for haemorrhoidectomy and 3 days for rubber band ligation (P < 0.001). Rubber band ligation as an outpatient procedure is an effective treatment for second- and third-degree haemorrhoids and should be considered before recourse to surgery.", "provenance": [ { "field": "population", "quote": "One hundred patients with second- or third-degree haemorrhoids" }, { "field": "intervention", "quote": "rubber band ligation" }, { "field": "comparator", "quote": "haemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "Haemorrhoidectomy relieved 44 of 45 patients and rubber band ligation relieved 34 of 43" }, { "field": "result", "quote": "Haemorrhoidectomy relieved 44 of 45 patients and rubber band ligation relieved 34 of 43 (P < 0.05)" }, { "field": "result", "quote": "Mean time off work was 32 days for haemorrhoidectomy and 3 days for rubber band ligation (P < 0.001)" }, { "field": "n", "quote": "One hundred patients with second- or third-degree haemorrhoids were randomly allocated to haemorrhoidectomy (50) or rubber band ligation (50)" }, { "field": "followUp", "quote": "One year after treatment" } ] }, { "id": "pmid:301845", "pmid": "301845", "doi": null, "nctId": null, "pmcid": null, "title": "[Ambulatory hemorrhoidectomy through rubber band ligation-review of the literature]", "firstAuthor": "Wienert", "multipleAuthors": false, "journal": "Fortschr Med", "year": 1977, "design": "systematic-review", "n": 3244, "nField": "reported", "population": "patients with internal hemorrhoids", "intervention": "rubber band ligation treatment for hemorrhoids", "comparator": "no direct comparator; discussed relative to sclerotherapy and surgical hemorrhoidectomy", "primaryOutcome": "pain experienced and freedom from symptoms after treatment", "result": "80% of patients were free of symptoms afterward, with most reporting no or mild pain during treatment", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this is an older literature review pooling case histories without a controlled comparison group, so it can't reliably prove the treatment works better than alternatives.", "directness": "indirect", "limitations": "abstract does not describe study design details, randomization, or control group; it is a review of case histories only", "followUp": "", "plainFinding": "Most symptom-free after band ligation.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/301845/", "sourceText": "The value of rubber band ligation in the treatment of haemorrhoids is discussed and the literature on the case histories of 3244 patients who were treated by this technique is reviewed. 36% of the patients found this form of therapy to be painless, 41% suffered little and 14% severe pain. 80% of all patients finally were free of symptoms. Rubber band ligation therefore is an effective method treating internal haemorrhoids. Its advantages are simplicity, relatively little discomfort for the patient, applicability in ambulant patients, no general anaesthesia, low cost and good results with only minor complications. Thus it is an alternative to sclerotherapy and to surgical haemorrhoidectomy.", "provenance": [ { "field": "n", "quote": "the literature on the case histories of 3244 patients who were treated by this technique is reviewed" }, { "field": "population", "quote": "internal haemorrhoids" }, { "field": "intervention", "quote": "Rubber band ligation" }, { "field": "comparator", "quote": "an alternative to sclerotherapy and to surgical haemorrhoidectomy" }, { "field": "primaryOutcome", "quote": "36% of the patients found this form of therapy to be painless, 41% suffered little and 14% severe pain. 80% of all patients finally were free of symptoms." }, { "field": "result", "quote": "80% of all patients finally were free of symptoms." } ] }, { "id": "pmid:946447", "pmid": "946447", "doi": null, "nctId": null, "pmcid": null, "title": "Diagnosis of Meckel diverticulum by sodium pertechnetate Tc 99m scan", "firstAuthor": "Cooper", "multipleAuthors": false, "journal": "JAMA", "year": 1976, "design": "case-series", "n": 1, "nField": "reported", "population": "a 2-year-old child with painless rectal bleeding", "intervention": "sodium pertechnetate Tc 99m scan to find the cause of bleeding", "comparator": "", "primaryOutcome": "whether the scan could detect Meckel diverticulum as the cause of bleeding", "result": "the scan correctly identified Meckel diverticulum before surgery, but this type of scan misses the problem in about half of cases", "resultDirection": "mixed", "quality": "very-low", "qualityWhy": "this is a single child's case, not a study comparing treatments or testing a larger group", "directness": "indirect", "limitations": "only one patient described; the abstract itself says the test misses the diagnosis in about half of all cases of this condition", "followUp": "", "plainFinding": "Scan found hidden intestinal pouch causing bleeding.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/946447/", "sourceText": "Meckel diverticulum was diagnosed preoperatively as the cause of recurrent rectal bleeding in a 2-year-old child by means of a sodium pertechnetate Tc 99m scan. Although false-negative scans have been reported to occur in approximately 50% of all cases of Meckel diverticulum, the procedure should be considered in any case of unexplained, painless rectal bleeding, especially in pediatric patients.", "provenance": [ { "field": "n", "quote": "a 2-year-old child" }, { "field": "population", "quote": "recurrent rectal bleeding in a 2-year-old child" }, { "field": "intervention", "quote": "sodium pertechnetate Tc 99m scan" }, { "field": "primaryOutcome", "quote": "Meckel diverticulum was diagnosed preoperatively as the cause of recurrent rectal bleeding" }, { "field": "result", "quote": "false-negative scans have been reported to occur in approximately 50% of all cases of Meckel diverticulum" }, { "field": "limitations", "quote": "Although false-negative scans have been reported to occur in approximately 50% of all cases of Meckel diverticulum" } ] } ], "faqs": [ { "q": "Does blood in stool mean cancer?", "a": "Usually not. In one large community survey, only 1 in 709 people with rectal bleeding was diagnosed with colorectal cancer. But because cancer is one of the possible causes, and studies disagree on exactly how common it is, any new painless bleeding is worth having checked." }, { "q": "Is bright red blood in stool bad?", "a": "Bright red blood usually comes from the lower colon or rectum and is most often linked to hemorrhoids, diverticulosis, or a rectal ulcer rather than an emergency. Still, studies show it can occasionally signal something more serious, so it shouldn't be ignored, especially if it continues or is heavy." }, { "q": "What does it mean if my poop is lined with blood (just a little)?", "a": "Small streaks of blood on the outside of stool are most often described with hemorrhoids or minor irritation near the anus in the studies reviewed here. A doctor can usually tell this apart from bleeding coming from higher up in the bowel with a simple exam." }, { "q": "What causes bright red blood when you poop?", "a": "In the largest study looking at this, the most common findings were diverticulosis (small pouches in the colon wall), rectal ulcers, hemorrhoids, and abnormal blood vessels in the bowel lining. Less often, case reports describe rarer causes such as polyps, tumors, or inflammatory conditions." }, { "q": "Should I just wait and see if it stops on its own?", "a": "No — waiting isn't supported by this evidence. Because studies show painless bleeding can occasionally come from a rectal ulcer, bowel tissue damage, a medication reaction, or cancer, the safer step is to see a doctor for an exam, and a colonoscopy if recommended, rather than watching and waiting." }, { "q": "If something could be seriously wrong, what should I do instead of waiting?", "a": "See a doctor or go to urgent care to get examined rather than watching and waiting, since painless blood in the stool can come from very different sources — from hemorrhoids to rectal ulcers to, less often, polyps or cancer — and you can't tell which from symptoms alone. In one large study of adults hospitalized with this type of bleeding, colonoscopy found a specific cause in about 95% of cases, so a direct look is what actually answers the question. If bleeding is heavy, recurs, or comes with weakness or dizziness, treat it as an emergency and seek care right away rather than trying to manage it at home." } ], "searchedAs": [ "why am i pooping blood no pain", "why am i bleeding when i poop but no pain", "what does it mean if my poop is lined with blood little", "is bright red blood in stool bad", "what causes bright red blood when you poop", "does blood in stool mean cancer", "why am i pooping blood no pain male", "what happens if there is blood in your poop" ], "patientTakeaway": "See a doctor and ask for an exam, and a colonoscopy if they recommend one — especially if the bleeding continues, you're over 45, or you also have tiredness, weight loss, or a change in bowel habits. Most people found to have painless rectal bleeding have a treatable cause like hemorrhoids or diverticulosis, but studies show a minority have something more serious, and only an exam can tell the difference safely.", "methodology": { "databases": [ "PubMed", "ClinicalTrials.gov", "Crossref" ], "searchStrings": { "pubmed": "(\"Gastrointestinal Hemorrhage\"[Mesh] OR \"Hematochezia\"[tiab] OR \"rectal bleeding\"[tiab] OR \"blood in stool\"[tiab]) AND (\"Hemorrhoids\"[Mesh] OR \"Fissure in Ano\"[Mesh] OR \"Colorectal Neoplasms\"[Mesh] OR etiology[tiab] OR cause[tiab] OR causes[tiab]) AND (painless[tiab] OR \"no pain\"[tiab])" }, "pubmedQueryTranslation": "(\"Gastrointestinal Hemorrhage\"[MeSH Terms] OR \"Hematochezia\"[Title/Abstract] OR \"rectal bleeding\"[Title/Abstract] OR \"blood in stool\"[Title/Abstract]) AND (\"Hemorrhoids\"[MeSH Terms] OR \"Fissure in Ano\"[MeSH Terms] OR \"Colorectal Neoplasms\"[MeSH Terms] OR \"etiology\"[Title/Abstract] OR \"cause\"[Title/Abstract] OR \"causes\"[Title/Abstract]) AND (\"painless\"[Title/Abstract] OR \"no pain\"[Title/Abstract])", "searchedOn": "2026-10-13", "inclusion": [ "Human, animal or laboratory studies reporting an outcome relevant to the question" ], "exclusion": [ "Records about a different condition or intervention", "Records reporting no outcome", "Retracted publications, which are listed but excluded from every count" ], "extractionLevel": "abstract", "gradingNote": "Evidence strength is adapted from the GRADE framework. It is not a GRADE assessment and was not produced by a GRADE panel.", "limits": [ "Fields were read from abstracts, not full text, so detail reported only in a paper's methods section is not captured." ] }, "seo": { "title": "Pooping Blood With No Pain: What Studies Found", "description": "Painless blood in stool usually comes from hemorrhoids or similar causes; 104 studies show cancer is rare but serious causes exist." }, "lastChecked": "2026-10-13", "lastChanged": "2026-10-13", "nextCheckDue": "2026-11-13", "history": [], "pipeline": { "screenModel": "claude-haiku-4-5", "extractModel": "claude-sonnet-5", "composeModel": "claude-sonnet-5", "promptVersion": "ev-1", "ranOn": "2026-10-13" }, "status": "published" }