Delayed-onset bleeding after transrectal prostate biopsy presenting as a rectal Dieulafoy’s lesion

Rectal bleeding is a well-known adverse event related to transrectal prostate biopsy, with a frequency ranging from 0 % to 37 % [1]. Most bleeding is mild and resolves with conservative management. Severe bleeding, affecting up to 1 % of patients undergoing transrectal prostate biopsy, is uncommon but can be life-threatening [2]. Rectal bleeding typically occurs immediately after the biopsy. Delayed-onset bleeding is rare although several cases have been reported [3] [4]. Herein, we present a case of delayed-onset severe bleeding after transrectal prostate biopsy, which was successfully treated with endoscopic clipping ([Video 1]).

Video 1 Endoscopic diagnosis and treatment for delayed-onset rectal bleeding after transrectal prostate biopsy presenting as a rectal Dieulafoy’s lesion.

A 77-year-old man with a high prostate-specific antigen level underwent transrectal prostate biopsy. The patient developed hematochezia and hemorrhagic shock 5 days after the biopsy. The blood test revealed a drop in the hemoglobin level from 13.6 to 8.2 g/dL. The patient was referred to our department because digital compression did not achieve hemostasis. Emergency colonoscopy revealed a massive fresh clot in the rectum ([Fig. 1]), and we identified a pulsatile large-caliber vessel on the anterior wall of the rectum ([Fig. 2]). The vessel was surrounded by normal mucosa, which confirmed the diagnosis of Dieulafoy’s lesion ([Fig. 3]). We performed endoscopic hemostasis with clipping ([Fig. 4]). Active bleeding was observed when we placed the first clip; however, a total of three clips achieved hemostasis. The patient had no further bleeding and was discharged without additional interventions.

Fig. 1 Massive fresh clot in the rectum.

Fig. 2 Forward view of a pulsatile, large-caliber vessel on the anterior wall of the rectum.

Fig. 3 Retroflex view of the protruding vessel surrounded by normal mucosa.

Fig. 4 Endoscopic image after endoscopic clipping for hemostasis.

Interestingly, in this case, delayed-onset bleeding presented as Dieulafoy’s lesion. The mucosal defect created by the biopsy needle might have caused the exposure of the underlying submucosal artery to the rectal lumen. A recent case-based systematic review reported the efficacy of endoscopic therapy for severe bleeding after transrectal prostate biopsy [5]. In addition, this case highlights the importance of early endoscopic intervention to improve the patient’s outcome in such cases.

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• References

• 1 Quinlan MR, Bolton D, Casey RG. The management of rectal bleeding following transrectal prostate biopsy: a review of the current literature. Can Urol Assoc J 2018; 12: E146-E153
• 2 Brullet E, Guevara MC, Campo R. et al. Massive rectal bleeding following transrectal ultrasound-guided prostate biopsy. Endoscopy 2000; 32: 792-795
• 3 Ustündağ Y, Yeşilli C, Aydemir S. et al. A life-threatening hematochesia after transrectal ultrasound-guided prostate needle biopsy in a prostate cancer case presenting with lymphedema. Int Urol Nephrol 2004; 36: 397-400
• 4 Ando T, Watanabe K, Mizusawa T. et al. Late-onset rectal bleeding with hemorrhagic shock after transrectal prostate needle biopsy. Urol Case Rep 2018; 21: 41-43
• 5 Malik A, Ishtiaq R, Goraya MHN. et al. Endoscopic therapy in the management of patients with severe rectal bleeding following transrectal ultrasound-guided prostate biopsy: a case-based systematic review. J Investig Med High Impact Case Rep 2021; 9 23247096211013206.