Bleeding Beyond the Line: Anorectal Melanoma as a Cause of Lower Gastrointestinal Bleeding
- PDF / 4,796,687 Bytes
- 3 Pages / 595.276 x 790.866 pts Page_size
- 91 Downloads / 185 Views
CASE REPORT
Bleeding Beyond the Line: Anorectal Melanoma as a Cause of Lower Gastrointestinal Bleeding Huy D. Phan 1 & Hongying T. Tan 2,3 & James H. Tabibian 3,4 Accepted: 28 October 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Introduction Anorectal melanoma is a rare neoplasm that accounts for approximately 1% of all melanomas and 0.5–2% of all anorectal malignancies [1]. It can present nonspecifically as hematochezia or bright red blood per rectum (BRBPR) associated with a rectal mass, similar to hemorrhoidal or other gastrointestinal bleeding sources. The diagnosis of anorectal melanoma may be challenging to make given its rarity, nondescript presentation, and need for histopathology. However, accurate and timely diagnosis allows for the exploration of potential treatment options that may slow disease progression in this aggressive and highly fatal malignancy.
Case Report An 88-year-old Hispanic male was admitted to the intensive care unit for septic shock after being found lethargic and dyspneic at his skilled nursing facility. He was started on intravenous antibiotics and vasopressors and intubated for airway protection. Though slowly improving overall, on hospital day 6, he had four episodes of large red clots per rectum. Rectal examination showed BRBPR and a rubbery lesion palpable on the posterior rectal wall without visible hemorrhoids. Computed tomography of the abdomen and pelvis was
performed and reported as being significant for a large fecaloma without other evidence of colonic abnormality or explanation for the ongoing bleeding (Fig. 1). Due to the drop in hemoglobin to 6.3 g/dL, the patient was transfused 2 units of packed red blood cells, empirically started on intravenous pantoprazole, and administered parenteral vitamin K as well as a dose of desmopressin in light of his coagulopathy and uremia, respectively. Over the next 2 days, the patient continued to have multiple bowel movements with blood clots requiring additional transfusions of blood products. Given these collective findings, the patient underwent flexible sigmoidoscopy which revealed a 3cm ulcerated mass in the distal rectum which involved the dentate line (Fig. 2). Endoscopic hemostasis was not feasible, but a biopsy was obtained with resultant stains (Figs. 3 and 4) diagnostic of malignant melanoma invading the lamina propria and muscularis with associated ulceration and necrosis. Considering the patient’s age, clinical status, multiple comorbidities, and baseline advanced dementia, the primary medical team, multidisciplinary tumor board, and unrepresented patient committee agreed that it was ethically appropriate to not pursue further workup or treatment of the patient’s melanoma under the concept of nonbeneficial care. Following clinical improvement and stabilization of his acute medical conditions, the patient was extubated and eventually discharged to his skilled nursing facility with comfortoriented care.
* Huy D. Phan [email protected]
Discussion 1
Department of Medicine, Olive View-U
Data Loading...
