A 79-year-old man had a diagnosis of carcinoma of the prostate established in 2020. He had received pelvic radiotherapy as part of his oncological management. The radiotherapy modality (external beam vs brachytherapy), total dose, fractionation schedule, and interval from radiotherapy completion to onset of rectal bleeding were documented in the oncology treatment record but were not available for reproduction in this report. He had been treated with abiraterone, subsequently switched to enzalutamide 160 mg daily due to biochemical progression. Serial prostate-specific antigen monitoring demonstrated rapid biochemical progression: PSA 30.47 ng/mL (10/11/2025), 53.84 ng/mL (23/01/2026), 127.4 ng/mL (22/02/2026), and 227.4 ng/mL (02/04/2026)—a seven-fold rise over five months despite antiandrogen therapy (Table 1). Disease progression was confirmed on ⁶⁸Ga-PSMA PET/CT (18/04/2026), which demonstrated interval appearance of extensive PSMA-avid distant nodal and skeletal metastases compared with a prior scan (16/06/2025) (Table 2). He presented with severe anaemia (haemoglobin 7.7 g/dL), left malignant ureteric obstruction with post-renal AKI (creatinine 230.5 µmol/L), and persistent per rectal bleeding (Table 3). Two prior argon plasma coagulation (APC) sessions at KUTRH had achieved initial haemostasis but bleeding recurred (Table 4). A chronological timeline of multidisciplinary management is provided (Table 5).

Table 1. Pre-stenting comprehensive laboratory values (02/04/2026).

Table 2.⁶⁸Ga-PSMA PET/CT summary (18/04/2026).

Table 3. Serial laboratory trend.

Table 4. Sequential endoscopic interventions.

Table 5. Chronological multidisciplinary management timeline.

Oncology discussion identified potential treatment pathways including Lutetium-177 (¹⁷⁷Lu) PSMA-targeted radioligand therapy and systemic chemotherapy, both requiring adequate renal function, correction of severe anaemia, and control of active haemorrhage prior to initiation. The patient was therefore referred for multidisciplinary stabilisation (Table 5) before oncological treatment could be considered.

DiagnosticNote: Radiation proctitis was clinically documented at Kenyatta University Teaching and Referral Hospital (KUTRH) with a discharge diagnosis of radiation proctitis, ICD-10: K62.7. Histological confirmation was not obtained. The original radiotherapy dose, fractionation schedule, and rectal dose were not available for reproduction. The differential diagnosis includes malignant mucosal infiltration, ischaemic colitis, and malignancy-associated vascular ectasia. The documented clinical diagnosis at a tertiary referral centre, the characteristic endoscopic pattern confined to the irradiated rectal field with normal proximal colon, and the absence of pathological PSMA uptake in the rectum on PET/CT (which makes PSMA-avid malignant infiltration less likely, but does not exclude non-PSMA-avid microscopic disease or non-malignant causes) collectively support radiation proctitis as the primary working diagnosis.

The patient developed progressive left flank discomfort with biochemical evidence of renal dysfunction. Imaging confirmed left-sided hydronephrosis secondary to malignant ureteric obstruction from locally advanced prostatic disease and/or metastatic nodal compression. Serum creatinine at presentation was 230.5 µmol/L (Table 1), consistent with post-renal AKI superimposed on age-related baseline renal impairment, with serial laboratory trends from presentation to latest follow-up shown (Table 3). Serum electrolytes demonstrated mild hyponatraemia (sodium 134.6 mmol/L), borderline elevated potassium (5.50 mmol/L), and hypocalcaemia (calcium 2.06 mmol/L). Clinical assessment determined that malignant ureteric obstruction required urgent decompression. Haematuria was not present before any intervention.

The patient had persistent per rectal bleeding manifesting as frank blood per rectum, contributing to a haemoglobin of 7.7 g/dL with microcytic indices (MCV 78.8 fL, MCH 26.6 pg). Peripheral blood film demonstrated dimorphic anaemia with moderate anisocytosis, mixed normocytic normochromic and microcytic hypochromic populations, occasional ovalocytes, and polychromasia (3+), consistent with concurrent iron deficiency from chronic gastrointestinal blood loss and anaemia of chronic disease and/or chronic kidney disease contribution [8]. Possible marrow involvement is a differential consideration given the extensive skeletal metastases, but was not confirmed by bone marrow biopsy. Platelet count was adequate (416 × 10⁹/L). Packed red blood cell transfusion was recommended with a target of 9 - 10 g/dL to optimise physiological reserve prior to any oncological intervention.

The patient’s baseline functional status and medication list were not comprehensively documented in the reviewed records. Specifically, the Eastern Cooperative Oncology Group (ECOG) performance status, detailed comorbidity history, and current medication list—including any antiplatelet agents, anticoagulants, non-steroidal anti-inflammatory drugs, or iron supplementation—were not available for reproduction. Whether enzalutamide was held peri-procedurally was not documented. This is acknowledged as a limitation when interpreting bleeding risk and treatment selection.

Baseline echocardiography on 12/04/2026 demonstrated a preserved left ventricular ejection fraction of 58.2% but reduced stroke volume of 49.3 mL and low cardiac output of 3.4 L/min, with mildly reduced global longitudinal strain of −18.9% and features of heart failure with preserved ejection fraction physiology. Right ventricular function was preserved, and no pulmonary hypertension was documented. These findings supported cautious transfusion, fluid management, and cardiology-aware oncology planning.

Prior endoscopic documentation from KUTRH on 28/03/2025 recorded a clinical diagnosis of radiation proctitis (ICD-10: K62.7). Colonoscopy under sedation demonstrated a normal proximal colon, while the anus/rectum showed widespread friable mucosa that bled easily. These findings were consistent with radiation proctopathy confined to the irradiated field. Histological confirmation was not obtained. The original radiotherapy dose, fractionation schedule, and rectal dose were not available for reproduction.

A third colonoscopy was performed at Mt Elgon Endoscopy Center on 27/04/2026 using a water-assisted (underwater) technique for persistent recurrent bleeding after two prior APC sessions. Endoscopic findings included diffuse radiation proctopathy with circumferential rectal erythema, petechiae, telangiectatic vessels, and active oozing haemorrhage. No focal mass or ulceration was identified. The bleeding was diffuse across the irradiated mucosal field, consistent with the established clinical diagnosis of radiation proctitis (Figure 1).

Figure 1. Third colonoscopy at Mt Elgon Endoscopy Center (27/04/2026) using water-assisted technique. (A) Active bleeding and mucosal friability. (B) Underwater visualisation. (C) Cyanoacrylate glue cast achieving mechanical haemostasis. (D) Post-haemostasis assessment with reduced active bleeding.

A clinician-supervised real-time colonoscopy mapping interface was used before and during the third colonoscopy to review previously APC-treated segments and map current mucosal abnormalities by colonic segment (Figure 2, Figure 3). The clinician-supervised mapping interface helped document and visually correlate recurrent bleeding with previously APC-treated segments. The mapping system did not make autonomous diagnostic or therapeutic decisions; all interpretation and treatment decisions were made by the treating clinician. APC was not performed during the third colonoscopy; mapping was used in case a repeat APC became necessary.

Figure 2. AI-assisted real-time colonoscopy mapping interface. Colour-coded colon map with APC session history. Green = normal; red = abnormal. Clinician-supervised documentation and planning aid only. All patient identifiers should be redacted before submission.

Figure 3. Procedural sequence during water-assisted colonoscopy at Mt Elgon Endoscopy Center (27/04/2026). (A) Adrenaline (1:10,000) submucosal injection producing a visible wheal around the bleeding site. (B) N-butyl-2-cyanoacrylate (Histoacryl) glue injection via catheter, demonstrating targeted delivery to the bleeding mucosa. (C) Post-haemostasis assessment showing no active oozing and restored fine vascular pattern. All patient identifiers should be redacted before submission.

A non-contrast ⁶⁸Ga-PSMA PET/CT performed on 18/04/2026 for biochemical recurrence demonstrated interval progression compared with the prior PSMA PET/CT from 16/06/2025. The prostate measured approximately 74 mL and showed only low-grade physiological PSMA uptake without PSMA-avid local recurrence or residual disease. However, there were extensive PSMA-avid distant nodal metastases involving supraclavicular, infraclavicular, mediastinal, hilar, para-aortic, celiac, and left gastric nodal stations, as well as multiple PSMA-avid lytic/sclerotic skeletal metastases involving the cervical, thoracic, and lumbar spine, ribs, and right iliac bone. No pathological visceral PSMA uptake was reported; low-grade PSMA-avid bilateral lower lung zone opacities were interpreted as possibly post-infectious. Overall, the scan confirmed metastatic disease progression and supported urgent oncology reassessment after renal, haematologic, and gastrointestinal stabilisation. No pathological rectal PSMA uptake was reported; this makes PSMA-avid prostate cancer infiltration less likely, but does not exclude non-PSMA-avid microscopic disease or non-malignant inflammatory/ischemic causes.

On 07/04/2026, the patient underwent left antegrade Double-J ureteric stenting at Male Wellness & Urology Clinic for malignant left ureteric obstruction causing hydronephrosis and post-renal acute kidney injury (Table 5). The indication was therapeutic urinary decompression to restore renal drainage, improve renal function, avoid dialysis, correct metabolic risk, and preserve eligibility for systemic oncological therapy. Following stenting, serum creatinine improved from 230.5 µmol/L to 146 µmol/L (Table 3), potassium normalised, and dialysis was avoided.

Post-stenting KUB radiography confirmed satisfactory stent positioning (Figure 4). Urinary drainage was restored; transient macroscopic haematuria was observed as an expected post-procedural finding (Figure 5), which resolved spontaneously. Renal recovery was demonstrated by serial improvement in creatinine and potassium rather than by imaging alone. Bedside bladder ultrasonography demonstrated an echogenic curvilinear structure within the urinary bladder, consistent with the distal coil of the Double-J stent (Figure 6). This supported distal stent positioning but did not by itself prove complete resolution of obstruction.

Figure 4. KUB radiograph confirming left-sided double-J ureteric stent in situ. Nephrostomy catheter visible along the left flank.

Figure 5. Urinary drainage bag (Bardia) post-double-J stenting showing transient macroscopic haematuria (~500 - 600 mL), confirming restored urinary drainage from the obstructed left collecting system. Haematuria was a post-procedural observation, not the indication for stenting.

Figure 6. Bedside bladder ultrasonography demonstrating an echogenic curvilinear structure within the urinary bladder, consistent with the distal coil of the Double-J stent. This supported distal stent positioning but did not by itself prove complete resolution of obstruction.

APC #1 was performed at KUTRH on 28/03/2025 as a day-case procedure. APC was applied to the rectum at argon flow 2 L/min and 30 kV, as documented in the source report. Haemostasis was achieved. APC #2 was performed at KUTRH on 11/07/2025, identifying moderate telangiectasia with active bleeding in the sigmoid colon and rectum/anus; APC was applied to both areas, with a recommendation to repeat APC in 6 - 8 weeks. Despite two APC sessions over approximately four months, per rectal bleeding continued to recur. This is consistent with published recurrence rates [4]. Two of the recommended 2 - 3 APC sessions [3] were performed before escalation (Table 4).

Given recurrence despite two APC sessions, a third colonoscopy was performed at Mt Elgon Endoscopy Center using a water-assisted technique [9] (Table 4). Adrenaline (1:10,000) was injected submucosally at the bleeding sites to achieve initial vasoconstriction. N-butyl-2-cyanoacrylate (Histoacryl) was then mixed with Lipiodol (~1:1) and injected in 0.5 - 1.0 mL aliquots via a standard injection catheter into the submucosal plane at multiple sites across the bleeding field. The exact total injected volume, needle gauge, and number of injection sites were not fully captured in the retrospective procedural record. APC was not performed during this third procedure.

No immediate complications were observed. The procedure was associated with marked short-term bleeding reduction: no further large-volume per rectal bleeding was documented during the 3-day post-procedure observation period.

Potential risks of lower gastrointestinal cyanoacrylate include tissue necrosis beneath the cast, embolisation (low risk in capillary beds vs variceal shunts), interference with future endoscopic assessment, and unknown fate of retained rectal glue casts [6][10].

Rectal sucralfate suppositories were prescribed for 14 days [11]. Packed red blood cell transfusion was administered; haemoglobin improved from 7.7 g/dL (Table 1) to 9.0 g/dL (Table 6).

Table 6. Post-transfusion complete blood count (30/04/2026).

Radiation proctitis was favoured as the working diagnosis for three reasons. First, the clinical diagnosis was established at a tertiary referral centre (KUTRH) with ICD-10 coding (K62.7) and documented endoscopic findings of widespread friable mucosa confined to the irradiated rectal field with normal proximal colon [1][2]. Second, the patient had a history of pelvic radiotherapy for prostate cancer, and the endoscopic appearance (telangiectasia, diffuse friability, contact bleeding) is characteristic of chronic radiation proctopathy. Third, ⁶⁸Ga-PSMA PET/CT showed no pathological PSMA uptake in the rectum, making PSMA-avid malignant infiltration less likely, although it does not exclude non-PSMA-avid microscopic disease [2]. Histological confirmation was not pursued because the endoscopic pattern was classic for radiation proctopathy in the context of documented prior pelvic irradiation, and biopsy of friable post-radiation mucosa carries an increased bleeding risk in a patient with severe anaemia. Ischaemic colitis was considered unlikely because the presentation was chronic rather than acute, confined to the irradiated field, and not segmental. The original radiotherapy modality, total dose, fractionation schedule, and interval from radiotherapy to onset of rectal bleeding were not available for reproduction in this report.

APC is the first-line endoscopic therapy for radiation proctopathy [3,4]. Current guidelines recommend APC, bipolar electrocoagulation, heater probe, or radiofrequency ablation as effective endoscopic options for bleeding from chronic radiation proctopathy, with formalin reserved for select cases due to higher adverse event rates [12]. In this case, two APC sessions were performed at KUTRH (28/03/2025 and 11/07/2025) (Table 4). APC #1 treated the rectum; APC #2 identified extension to the sigmoid with ongoing telangiectasia and active bleeding. Despite two sessions over four months, bleeding recurred—consistent with published recurrence rates [4]. The clinician-supervised mapping interface helped document and visually correlate recurrent bleeding with previously APC-treated segments, supporting the decision to escalate to an alternative modality rather than pursuing a third APC session, particularly given concurrent anaemia severity and renal dysfunction.

Cyanoacrylate achieves mechanical haemostasis through rapid polymerisation [6][10]. In this case, it was associated with short-term bleeding control after two APC failures. It may represent a selected rescue option when standard endoscopic therapies have been exhausted, but durability and safety for chronic radiation proctopathy specifically require further study [12]. Risks include tissue necrosis, embolisation (low in capillary beds), interference with future assessment, and the unknown fate of retained rectal casts. Erythropoiesis-stimulating agents were considered as an adjunct, but the acute anaemia severity mandated immediate transfusion [13].

Water-assisted colonoscopy improves mucosal visualisation during active bleeding [9][14][15]. In this case, the water-assisted technique at Mt Elgon Endoscopy Center allowed better assessment of the diffuse bleeding field and guided targeted adrenaline and cyanoacrylate injection. The AI-assisted mapping interface provided clinician-supervised documentation of prior APC-treated segments and facilitated procedural planning, although all therapeutic decisions were made by the treating clinician.

Renal decompression was essential because malignant ureteric obstruction can cause progressive renal dysfunction and may limit the delivery of systemic cancer therapy [16]. In this patient, Double-J stenting restored urinary drainage, improved renal function, avoided dialysis, and supported oncology handover. Urinary diversion in malignant obstruction requires individualised decision-making that balances renal preservation against procedural burden and quality-of-life considerations [16]. Oncological treatment could not proceed without renal stabilisation and gastrointestinal bleeding control. Coordinated gastroenterology, urology, nephrology, haematology, and oncology management was essential [7][17][18].

Radiation proctitis is clinically documented (ICD-10: K62.7) but not histologically confirmed. The original radiotherapy modality, total dose, fractionation schedule, rectal dose, and interval from radiotherapy to onset of rectal bleeding were unavailable for reproduction in the reviewed record. Baseline functional status (ECOG), detailed comorbidity history, and complete medication list were not documented. Follow-up was 3 days post-procedure; long-term cyanoacrylate durability is unknown. Total glue volume, needle gauge, and exact number of injection sites were not fully captured in the retrospective procedural record. The number of PRBC units transfused and the transfusion rate were not documented. This is a single-case observation. Formal coronary artery disease workup (coronary CT angiography or stress testing) and transthyretin amyloid cardiomyopathy exclusion (technetium pyrophosphate scintigraphy) were not performed during this admission and remain outstanding before cardiotoxic chemotherapy.