A 54-year-old woman comes to the emergency department due to bright red blood per rectum. She reports passing 3 large, bloody stools over the past 2 days, which have been associated with mild abdominal cramps. The patient has no melena, fever, vomiting, or unexpected weight changes. She underwent a radical hysterectomy and adjuvant radiation therapy for cervical cancer over 12 months ago. The patient has no other medical conditions and takes no medication. Temperature is 37.5 C (99.5 F), blood pressure is 140/80 mm Hg, pulse is 80/min, and respirations are 12/min. Cardiopulmonary examination is unremarkable. The abdomen is nontender and nondistended. Extremities are warm and well perfused. Laboratory results are as follows: A colonoscopy is performed and shows mucosal pallor, friability, and multiple telangiectasias, all of which are confined within the rectum. Scattered diverticula are present but limited to the descending and transverse colon. Which of the following is the most likely diagnosis?

Question

A 54-year-old woman comes to the emergency department due to bright red blood per rectum.  She reports passing 3 large, bloody stools over the past 2 days, which have been associated with mild abdominal cramps.  The patient has no melena, fever, vomiting, or unexpected weight changes.  She underwent a radical hysterectomy and adjuvant radiation therapy for cervical cancer over 12 months ago.  The patient has no other medical conditions and takes no medication.  Temperature is 37.5 C (99.5 F), blood pressure is 140/80 mm Hg, pulse is 80/min, and respirations are 12/min.  Cardiopulmonary examination is unremarkable.  The abdomen is nontender and nondistended.  Extremities are warm and well perfused.  Laboratory results are as follows:  A colonoscopy is performed and shows mucosal pallor, friability, and multiple telangiectasias, all of which are confined within the rectum.  Scattered diverticula are present but limited to the descending and transverse colon.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d81e_d9df_bc81_4dc901d29dd9_MD0003_00 This patient with a history of cervical cancer treated with radiation therapy has hematochezia. In association with the characteristic rectal findings on colonoscopy, this presentation suggests chronic radiation proctitis (RP). RP occurs due to damage to the rectal epithelium associated with pelvic radiation therapy. Risk is related to intensity, duration, and type of radiation exposure. Manifestations of RP vary based on mechanism of mucosal injury. Acute RP occurs due to direct mucosal damage and presents ≤8 weeks postradiation with diarrhea, tenesmus, and mucus discharge. Chronic RP, which can arise months to years after radiation, occurs from submucosal fibrosis and obliterative endarteritis. The resulting tissue hypoxia promotes neovascularization and telangiectasia formation, which are prone to bleeding and often result in significant hematochezia and blood loss anemia; stricturing may occur. Colonoscopy in chronic RP demonstrates mucosal pallor, friability, and multiple telangiectasias confined to the rectum. Management includes local thermal coagulation or sucralfate and glucocorticoid enemas. (Choice A) Angiodysplasia is an arteriovenous malformation that usually occurs in elderly patients as well as those with chronic kidney disease and severe aortic stenosis. Although it morphologically resembles telangiectasia, the presence of colonic mucosal pallor and friability and the history of pelvic radiation is more consistent with RP. (Choice B) Clostridioides difficile typically presents with watery diarrhea, fever, and leukocytosis in individuals with recent antibiotic exposure. White pseudomembranes are expected on colonoscopy. (Choice C) Crohn disease can cause hematochezia but typically presents with abdominal pain, diarrhea, and perianal lesions. Colonoscopy typically demonstrates deep colonic ulcerations and skip lesions. In addition, although isolated rectal inflammation can occur in ulcerative colitis, it is extremely uncommon in Crohn disease. (Choice D) Diverticular colitis refers to mucosal inflammation immediately adjacent to diverticula. This patient's inflammatory changes are confined to the rectum, separate from the diverticula located in the descending and transverse colons. (Choice E) Ischemic colitis results from colonic hypoperfusion and typically affects intestinal watershed areas (eg, rectosigmoid junction, splenic flexure). Although hematochezia and abdominal cramps are common, ischemic colitis usually occurs in the setting of profound hypotension (eg, septic shock, acute heart failure). Educational objective: Radiation proctitis (RP) is caused by mucosal damage associated with pelvic radiation therapy. Acute RP presents ≤8 weeks postradiation with diarrhea, tenesmus, and mucus discharge, whereas chronic RP occurs months to years after radiation, resulting in hematochezia, anemia, and possibly strictures. Colonoscopy demonstrates mucosal pallor, friability, and telangiectasias confined to the rectum. References: Chronic haemorrhagic radiation proctitis: a review. (http://www.ncbi.nlm.nih.gov/pubmed/27462390)

A 54-Year-Old Woman Comes to the Emergency Department Due to Bright