Acute Lower Gastrointestinal Bleeding from a Dieulafoy lesion: Three Case Reports and a Literature Review

Abstract

Purpose: Dieulafoy lesion is a rare cause of gastrointestinal (GI) bleeding, accounting for 1-2% of cases. It can be seen anywhere in the GI tract but is usually found in the stomach. Here we present three cases of lower GI bleed secondary to Dieulafoy lesions. Case #1: 84-year-old man with history of prostate cancer treated with radiation therapy, and recurrent hematochezia for several years, was admitted with lower GI bleeding with hemodynamic compromise, and a hemoglobin of 5.2 g/dL. Prior upper endoscopy, colonoscopy and small bowel capsule endoscopy, were significant only for radiation proctitis. Colonoscopy, on this admission, revealed pools of bright red blood in the right colon, with a vessel protruding from a small mucosal defect in the ascending colon, spurting fresh blood. Hemostasis was achieved with four hemoclips. No further bleeding was reported. Case #2: 86-year old man presented with rectal bleeding. Colonoscopy revealed an actively bleeding exposed vessel in the rectum, without surrounding ulceration. Hemostasis was achieved with application of a hemoclip to the base of the vessel. No further bleeding was reported. Case #3: 64-year old woman presented with intermittent rectal bleeding. Colonoscopy revealed copious amounts of fresh blood in the rectum, and after careful irrigation and inspection, a pulsatile active bleeding site was identified with surrounding normal mucosa. Hemostasis was achieved by application of two hemoclips. No further bleeding was reported. Dieulafoy lesions are a rare cause of lower GI bleeding. While 75% of Dieulafoy lesions are found in the stomach; only 2% are in the colon, and 2% in the rectum. A Dieulafoy lesion, is a tortuous submucosal artery, which retains its large caliber as it approaches the mucosa, and protrudes through a small mucosal defect. The lesion ruptures spontaneously and bleeds massively for reasons that are unclear. In the colon, solid bowel contents may lead to stercoral ulceration with resultant exposure of the vessel and hemorrhage. Given the intermittent nature of the bleeding and normal appearance of the mucosa, repeated endoscopies are often necessary to make the diagnosis. A complete bowel prep to clear the colon of retained blood and colonic contents enables the endoscopist to see the characteristic appearance of a protruding vessel or blood spurting from a pinpoint mucosal defect, or otherwise normal appearing mucosa. Endoscopic therapeutic intervention is the treatment of choice. Hemostasis has been reported with thermal coagulation, mechanical (banding or hemoclip) therapy, or regional injection (epinephrine). Dieulafoy lesions should be included in the differential diagnosis of lower GI bleeding.