A unique case of ileal Dieulafoy's lesion diagnosed and treatedbycap-assisted water immersion colonoscopy.

Abstract

Ileal Dieulafoy’s lesions are rare causes of GI bleeding and are identified primarily through capsule endoscopy, single-balloon enteroscopy, or double-balloon enteroscopy. We describe a unique case of ileal Dieulafoy’s lesion identified and treated through cap-assisted water-immersion colonoscopy (Video 1, available online at www.VideoGIE.org). An 83-year-old woman with a history of transient ischemic attack on an aspirin regimen presented with a 5-day history of melena and anemia. She had a history of GI bleeding 1 year previously from presumed peptic ulcer and right-sided colonic arteriovenous malformations. Repeated EGD showed retained clips on previous ulcer sites. Colonoscopy showed a 1-cm nonbleeding ascending arteriovenous malformation with more proximal intermittent extrusion of fresh blood from the ileocecal valve. Advancement of a pediatric colonoscope (Evis Exera III PCF-PH190L/l; Olympus Medical Systems, Tokyo, Japan) with distal attachment cap (Reveal; US Endoscopy, Mentor, Ohio, USA) into the ileum revealed a trail of small scattered clots. Further advancement of the colonoscope 30 cm into the ileum (measured by withdrawal from the lesion to the ileocecal valve) demonstrated a 4-mm nonadherent clot. Irrigation of the clot uncovered a 1-mm actively pulsating bleeding vessel. Hemostasis was achieved with 3 hemoclips, and a tattoo was placed (Fig. 1). After discharge, no recurrent bleeding was observed. We highlight the use of cap-assisted water-immersion colonoscopy as a means to advance the colonoscope deeper into the small bowel compared with traditional gas distention colonoscopy. The cap extends the length of the colonoscope 3 to 4 mm, which allows the proximal adjacent intestinal folds to be pushed down ahead of the scope. In some areas where inevitable looping results and advancing the scope even 1 cm is difficult, the cap may assist in pushing down the proximal adjacent fold to help anchor the colonoscope forward and beyond where an otherwise introduced loop has difficulty advancing. Therapeutically, the cap stabilizes lesions into the field of view, preventing inadvertent deflection of the tip. The water-immersion method minimizes excessive looping and lengthening of the colon. The shortened colon length potentially allows more proximal advancement of the colonoscope. Deeper intubation of the ileum allows lesions like this one to be reached without the need for capsule or balloon enteroscopy. Cap-assisted water-immersion colonoscopy may allow more efficient and cost-effective means of identifying and treating ileal lesions thought to be otherwise unreachable by gas distention colonoscopy. All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0YmI5NTA1YmQ2ZDcxMzczNmFkNmJiNmU3ZTk5ZGNjZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NzQ4OTgwfQ.kUT-cUQDKFui2G-CNZc1qE2Xnpx_8VggXnt8HInPZ1TvsHQOAxBgrnGlQOrXb21rfpZsaBelzmgtc9QugNCH8jIEl0bwzSpqBj-hOyGqwahx7zMmrxqBkbF_XWU0Y-I9h-iyt_OxK_0vxGuPhe7-r4geZhxa-MZR6JSvu4t63wYcweKtN5YC6RadudcV3pjhJjo6B8XLf_lvRkrLMikeprWX06TON7qKuIP7MIFc0oboQmEKmh7you_wYi4YhKJFkAokaXdGUCjWlgAMx_a5xaBb-smXynCQVKSFYbXdhTNq41T5wbpshJJi0VyosoYFQFJGBCqpOVVbzao3upp8eg Download .mp4 (219.31 MB) Help with .mp4 files Video 1. Ileal intubation and endoscopic therapy with cap-assisted water-immersion colonoscopy.