1988 Rectal Dieulafoy's Lesion: Hemorrhagic Shock Due to a Rare Cause of Acute Lower GI Bleeding

Abstract

INTRODUCTION: Dieulafoy's lesions account for 1–2% of acute GI bleeding and are characterized by dilated aberrant submucosal vessels that erode the overlying epithelium in the absence of a primary ulcer. While the majority are found in the stomach (71%), they occur along other parts of the GI tract, however rectal sites are rare and only account for 1–2%. We present a case of massive LGIB due to a rectal Dieulafoy's lesion in a patient with intermittent hematochezia. CASE DESCRIPTION/METHODS: A 58-year-old female presenting with DKA had a hospital course complicated by necrotizing pneumonia requiring VATS and trach/PEG placement. Early in her admission she developed hematochezia with Hgb drop of 9.3 to 6.4 (baseline 12–13). EGD was unremarkable. Colonoscopy revealed a 1.5 cm clean based rectal ulcer that did not require intervention. 2 weeks later recurrent hematochezia presumably from rectal tube responded conservatively with TXA soaked Merocel packing. Hematochezia re-occurred 10 days later in the setting of a gradual drop in Hgb over the previous 2 weeks requiring 3u PRBCs(11.7 to 6.7 to 8.5). The following day she had large volume hematochezia with clots and was pale, diaphoretic, and less responsive with BP of 60/45, HR of 122 and Hgb of 5.8. Resuscitative efforts included IVF bolus, 4u PRBCs, 1u platelets, 2u FFP and pressor support. Patient continued to have active passage of multiple blood clots and after bedside evaluation we elected to proceed with emergent bedside EGD/colonoscopy after 1 tap water enema. Initially CTA was considered due to the rapidity of her bleed and significant hemodynamic compromise, however patient developed AKI and was too unstable for transport. EGD was normal and colonoscopy revealed large amounts of blood in rectum, sigmoid and descending colon with brown stool proximal to splenic flexure and normal TI. The colon was irrigated and revealed a large clot in distal rectum which was injected with Epi and then removed, revealing normal mucosa. Continued irrigation revealed blushing and after careful endoscopic inspection an actively spurting small vessel was seen protruding through rectal mucosa without surrounding ulcer suggestive of a Dieulafoy's lesion. Three clips deployed with good hemostasis and site tattooed. Hgb remained stable and no recurrence of bleeding during hospitalization. DISCUSSION: This case highlights the importance of vigilance in the evaluation of recurrent LGIB with timely resuscitative and endoscopic measures in identifying a rare source of massive LGIB.