Case Report
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World J Clin Cases. Apr 16, 2014; 2(4): 86-89
Published online Apr 16, 2014. doi: 10.12998/wjcc.v2.i4.86
Rectal ulcers and massive bleeding after hemorrhoidal band ligation while on aspirin
Shruti Patel, Ghulamullah Shahzad, Kaleem Rizvon, Krishnaiyer Subramani, Prakash Viswanathan, Paul Mustacchia
Shruti Patel, Department of Internal Medicine, Nassau University Medical Center, New York, NY 11554, United States
Ghulamullah Shahzad, Kaleem Rizvon, Krishnaiyer Subramani, Prakash Viswanathan, Paul Mustacchia, Department of Gastroenterology, Nassau University Medical Center, New York, NY 11554, United States
Author contributions: Patel S performed an extensive literature review and drafted the case report; Shahzad G had substantial contributions in literature review and primary revision; Rizvon K, Subramani K and Viswanathan P revised it critically for important intellectual content; Mustacchia P provided the final revisions, supervised the process and gave the final approval of the version to be published.
Correspondence to: Shruti Patel, MD, Department of Internal Medicine, Nassau University Medical Center, East Meadow, New York, NY 11554, United States. drshrutipatel88@yahoo.com
Telephone: +1-516-5726501 Fax: +1-516-5725609
Received: January 18, 2013
Revised: March 8, 2014
Accepted: March 17, 2014
Published online: April 16, 2014
Abstract

Endoscopic hemorrhoidal band ligation is a well-established nonoperative method for treatment of bleeding internal hemorrhoids (grade 1 to 3). It is a safe and effective technique with a high success rate. Complications with this procedure are uncommon. Although rectal ulceration due to band ligation is a rare complication, it can cause life-threatening hemorrhage especially when patients are on medications which impair hemostasis like aspirin or non steroidal anti-inflammatory drugs. We present 2 cases of massive lower gastro-intestinal bleeding in patients who had a band ligation procedure performed 2 wk prior to the presentation and were on aspirin at home. Both the patients were hemodynamically unstable requiring resuscitation. They required platelet and blood transfusions and were found to have rectal ulcers on colonoscopy done subsequently. The rectal ulcers corresponded to the site of band ligation. The use of aspirin by these patients would have caused defects in the hemostasis and may have predisposed them to massive bleeding in the presence of rectal ulcers occurring after the band ligation procedure. Managing aspirin before and after the ligation may be difficult especially since adequate guidelines are unavailable. Stopping aspirin in all the cases might not be safe and the decision should be individualized.

Keywords: Hemorrhoids, Rubber band ligation, Rectal ulcers, Massive bleeding, Aspirin

Core tip: Rubber band ligation is known to be a relatively safe procedure. Massive bleeding and rectal ulceration is a very rare complication of this procedure. We came across two cases of severe, life-threatening lower gastrointestinal hemorrhage following endoscopic hemorrhoidal band ligation in patients on aspirin. The use of aspirin and other non-steroidal anti-inflammatory drugs can predispose to massive hemorrhage. The case report aims at creating awareness about these complications and that it may be advisable to avoid aspirin and non steroidal anti-inflammatory drugs immediately after band ligation.