A MULTIMODAL APPROACH TO CONTROL OF MASSIVE HEMORRHAGE SECONDARY TO RECTAL CANCER

Objectives: An 87-year-old veteran underwent outpatient EGD and colonoscopy to investigate several months of fecal incontinence and 10 pounds unintended weight loss. He had a history of hypertension, diabetes mellitus, CAD with prior CABG and coronary stent, TURP for BPH earlier that year, sigmoid resection for diverticulosis, and left hemicolectomy and chemotherapy for colorectal cancer 30 years prior. Massive hematochezia commenced shortly after initiation of conscious sedation. Colonoscopy revealed a colon full of fresh blood (A) and a 5cm friable mass involving the dentate line which was injected with epinephrine. He was transferred to the intensive care unit for hemodynamic monitoring and transfusion. CT angiography revealed a 7cm presacral mass displacing the rectum with inflammation of the rectal wall, new from a previous scan done five months earlier.

His symptoms resolved for approximately 24 hours until he developed numerous rapid episodes of hematochezia. Repeat CTA showed a high attenuation focus in the rectum suggestive of active hemorrhage (B). He became acutely hypotensive and experienced a brief cardiac arrest. Massive transfusion protocol was activated and spontaneous circulation was restored with return of mental status. Emergent focused pelvic angiography identified extensive tumor enhancement and possible blush off the anterior division of the right internal iliac artery from multiple parasitized vessels (C). The main trunk of the right internal iliac artery was embolized with multiple detachable microcoils to decrease the overall tumor blood supply and slow the rate of bleeding (D). The patient was taken directly from the angiography suite to radiation oncology for planning CT and within several hours underwent his first session of short course radiation, 25 Gy delivered over 5 fractions. In total, he received 10 PRBC, 8 FFP, and 1 pack of pooled platelets. Pathology was suspicious for small cell rectal carcinoma.

The management of patients with symptomatic rectal carcinoma can be challenging and is further complicated in cases of advanced age, comorbidities, previous surgical history, and acute life-threatening hemorrhage. In conjunction with angioembolization, inpatient short-course RT can be an effective treatment modality for advanced symptomatic rectal cancers not amenable to surgical resection. Recent case reports show that palliative RT is generally well tolerated and patients can experience benefits with minimal risk of grade 4 radiation toxicity. This case report demonstrates the utility of a multimodal approach and early inpatient collaboration between general surgery, gastroenterology, interventional radiology, and radiation oncology when caring for complex CRC patients with life-threatening tumor-related hemorrhage.

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