Portal de Periódicos da CAPES

Ischemic rectal necrosis after aortic valve replacement surgery successfully treated with conservative management

2021; Volume: 84; Issue: 1 Linguagem: Inglês

10.51821/84.1.646

1784-3227

Emanuel Dias, João Santos‐Antunes, Susana Lopes, Guilherme Macedo,

Cardiac Valve Diseases and Treatments

To the Editor,An 80-year-old female with history of aortic stenosis, heart failure, atrial fibrillation, hypertension and dyslipidemia underwent aortic valve replacement surgery.At 4 th postoperative day (POD), she developed hemodynamic instability, followed by abdominal pain and bloody diarrhea.Abdominal computed tomography (CT) revealed wall thickening from descending colon to rectum and peri-rectal fat stranding (Figure 1).Sigmoidoscopy demonstrated diffuse dark purple discoloration of rectal mucosa with interspersed areas of ulceration (Figure 2) that extended to sigmoid, consistent with gangrenous ischemic proctosigmoiditis.Considering the importance of postoperative anticoagulation after placement of the mechanical aortic valve, emergency surgery was avoided.Vasopressor support, broad-spectrum intravenous antibiotics and bowel rest were started.She was closely monitored and, fortunately, evolved favorably with clinical and hemodynamical improvement.At 24 th POD, there was symptomatic recurrence and sigmoidoscopy revealed friable granular rectal mucosa with no signs of active ischemia (Figure 2B).CMV was isolated in biopsies and valganciclovir was started with good response.At 65 th POD, sigmoidoscopy revealed healing mucosa with areas covered by white exudate (Figure 2C).Biopsies were still weakly positive for CMV.Considering clinical and endoscopic improvement, it was interpreted as residual changes during the course of disease resolution.At 83 rd POD, she was discharged home.Ischemic proctosigmoiditis is rare because rectum has an excellent collateral arterial network.It usually affects elderly patients with multiple cardiovascular risk factors that present with abdominal pain, diarrhea and/or hematochezia in the setting of hemodynamic compromise or vascular surgery.CT may demonstrate wall thickening and peri-rectal fat stranding.Endoscopy may reveal erythema, ulceration or hemorrhages and, in more severe cases, necrosis (1).It may be difficult to distinguish from inflammatory bowel disease, infectious colitis or neoplasia (2).Conservative management with supportive care, broad-spectrum antibiotics and close monitoring for signs of sepsis and perforation is usually sufficient for mild cases.In more severe cases, with deep ulceration, bleeding,