Dieulafoyʼs Lesion of Ano-Rectum: An Unusual Etiology of Lower Gastrointestinal Bleeding

Abstract

Dieulafoy's lesion (DL) represents a dilated aberrant submucosal artery that erodes through the overlying mucosa in the absence of an underlying ulcer, aneurysm or intrinsic mural abnormalities. It is the culprit for 1-2% of acute gastrointestinal (GI) bleeding which in this setting could be potentially life-threatening. DL commonly occurs in stomach and rarely develops in anorectum where it could be under-recognized due to lack of proper endoscopic visualization. We report the case of a middle-aged man presenting with lower GI bleeding due to an anal DL. 59 year old male presents with recurrent painless rectal bleeding of few months duration. He reports a history of deep vein thrombosis for which he is maintained on coumadin. Vital signs were stable. Physical examination noted fresh blood in the rectal vault with no obvious external hemorrhoids. Hemoglobin level was 9 g/dL on admission with a baseline of 13 g/dL (Normal 14-18) and an International Normalized Ratio (INR) of 3.9 (Normal 0.65-1.3). Colonoscopy revealed an actively bleeding protruding vessel in the anal canal just above the pectinate line, suggestive of DL (Fig. 1). Three resolution clips were applied with full control of bleeding (Fig. 2). Rest of the colon till cecum was unremarkable. Patient had no further bleeding afterward, hemoglobin remained stable and he was discharged home 3 days later. Dieulafoy's lesion was first described in 1898 by Sir Paul Georges Dieulafoy, when he studied three young men who died of gastric hemorrhage. Since then, DL became a well-known cause of massive GI bleeding. DL occurs mainly in the upper GI tract with around 70% of lesions involving the stomach, 18% in the duodenum, 8% in the esophagus and 4% in the colorectal area. No causative factors have been determined. However, DL is mainly seen in the context of cardiovascular disease, alcohol abuse, diabetes mellitus, kidney disease and Non-Steroidal Anti-Inflammatory Drug users. Diagnosis is challenging since most lesions reside in the resulting blood pool. Moreover, DL can be overlooked if it occurs in atypical locations like in our patient. Endoscopic intervention remains the therapeutic modality of choice in almost 90% of cases while surgery is typically reserved for recurrent bleeding. Heightened awareness of anal Dieulafoy's lesions is recommended, especially that traditional diagnoses like hemorrhoids and anal fissures are almost always favored, which leads to potential misdiagnosis and worse outcome.1997_A Figure 1. Colonoscopy showing protruding vessel with active bleeding and normal surrounding mucosa suggestive of Dieulafoy's lesion1997_B Figure 2. Full control of bleeding after application of resolution clips in the anal canal.