All patients underwent colonoscopy using a standard lower endoscope (CF-130I; Olympus, Tokyo, Japan and CFQ-260AI; Olympus). For endoscopic hemoclip placement (EHP), a hemostatic hemoclip (135-degree angle, HX-610-135; Olympus Optical Co., Ltd., Tokyo, Japan) was applied to the protruding vessels or adherent clots in the surrounding tissue. For endoscopic band ligation (EBL), a varioligator kit with a single-shot device (ConMed Cooperation, New York, NY, USA) was used. Endoscopic thermocoagulation was performed using a coagulation probe (MTW, Wesel, Germany).

A 65-year-old woman with a history of type 2 diabetes presented with profuse hematochezia while undergoing postoperative management of a femur neck fracture in a local medical center. She complained of constipation for 4 days. She was pale, with a blood pressure (BP) of 118/75 mm Hg and a pulse of 99 beats per minute. Her initial hemoglobin level was 6.3 g/dL, and she received three units of packed red blood cells (PRBCs). She was initially evaluated using flexible sigmoidoscopy, which did not reveal any evidence of bleeding. She did not complain of hematochezia for 3 days, and her vital signs were stable. She was transferred to the previous hospital, and we planned elective colonoscopy 2 weeks later. However, she was transferred to our hospital several hours later owing to repeated episodes of hematochezia. Our second evaluation included normal endoscopy and abdominal computed tomography (CT) scans, which reveal thickening of the rectum wall. She did not complain of hematochezia thereafter, and we carried out elective colonoscopy 3 days later. In this evaluation, multiple shallow erosions with a 3 mm protuberance and an adherent clot were identified. The lesion was treated with EBL. There had been no recurrence of bleeding after 2 months of follow-up.

A 68-year-old man with a history of small cell lung cancer with multiple bone metastases presented with profuse hematochezia. He described a 2-month history of severe constipation after undergoing chemotherapy. Initial examination revealed a pale conjunctiva, a pulse of 95 beats per minute and a BP of 158/106 mm Hg. His initial hemoglobin level was 8.1 g/dL, requiring transfusion of two units of PRBCs. He experienced another large volume hematochezia and decreased BP of 74/54 mm Hg, and required further transfusion. Our initial examination included a normal abdominal CT scan, normal upper endoscopy, and emergent rectoscopy, which revealed a 2 mm protuberance with an adherent clot within a field of shallow ulceration in the rectum. EBL was performed but primary hemostasis failed. The lesion was subsequently treated with EHP (Fig. 1). No further bleeding had occurred after a follow-up of 6 months.

A 75-year-old man was transferred from an outlying hospital because of uncontrolled hematochezia. Evaluation at the prior hospital included normal upper endoscopy and colonoscopy, which revealed a minute rectal mucosal defect with an associated exposed vessel. The lesion was treated with an injection of epinephrine, but hematochezia recurred several hours later. On arrival, his vital signs and physical examination results were normal. His initial hemoglobin level was 10.0 g/dL and had fallen to 6.6 g/dL, requiring transfusion of three units of PRBCs during hemodialysis. Colonoscopy revealed a shallow ulcer with a large protruding vessel and adherent clot. The lesion was treated with three EHPs. No further bleeding occurred for 3 days and he was transferred to a local medical center.

A 71-year-old-man with a history of intermittent hematochezia for 2 days was transferred from a local medical center. He was admitted to the intensive care unit to manage congestive heart failure, and pulmonary edema was treated using diuretics. However, owing to his delirious mentality, he was admitted to the intensive care unit for 15 days. On arrival, his vital signs were normal, and his hemoglobin level was 9.5 g/dL. Prepped colonoscopy was performed and revealed an exposed vessel with a minute mucosal defect in the distal rectum. The lesion was treated with EHP. However, after 4 days he passed approximately 100 mL of hematochezia. Colonoscopy detected no evidence of bleeding at the previously clipped lesion. However, another exposed vessel with a superficial ulcer was detected and treated using EBL. No further bleeding had occurred after 4 days and he was transferred to a secondary medical center.

A 65-year-old woman experienced bright red rectal bleeding during postoperative care for tongue cancer in an intensive care unit, and was suffering from postoperative complications such as infection and bleeding of the anastomosis site. On arrival at our department, her vital signs and abdominal examination results were normal. Her hemoglobin level increased from 8.0 to 9.4 g/dL after the transfusion of two units of PRBCs. Colonoscopy identified a protruding vessel surrounded by normal mucosa, 8 cm above the anal verge. The lesion was treated with EBL (Fig. 2, Supplementary Video 1 [available online at http://www.e-ce.org/]). After 22 months of follow-up, the patient was in good health.

A 68-year-old woman with hypertension was transferred to our hospital owing to recurrent episodes of hematochezia. She had been admitted for the evaluation of hematochezia including colonoscopy, which revealed a rectal ulcer and an internal hemorrhoid. Initial vital signs and physical examination results were normal. Her baseline hemoglobin level was 9.0 g/dL and had fallen to 6.4 g/dL, requiring multiple transfusions. Colonoscopy revealed multiple ulcers and a small adherent clot surrounded by relatively normal mucosa in the distal rectum. The lesion was treated with thermocoagulation by a heat probe. There was no further bleeding during hospitalization and after 1 month of follow-up.