S2152 Hypovolemic Shock Due to an Anal Dieulafoy Lesion

Abstract

INTRODUCTION: Dieulafoy lesions (DL) are dilated submucosal vessels that erode the overlying epithelium. They account for 2–3% of all GI bleeds (GIB). They can occur in any location of the gastrointestinal tract (GIT); however, they are mainly found in the stomach. We present a case of hematochezia resulting in hypovolemic shock from an anal Dieulafoy lesion. CASE DESCRIPTION/METHODS: A 71-year-old male with HTN, DM, PVD on ASA and stage 4 lung cancer on chemo-radiation was admitted for painless hematochezia. Rectal exam revealed dark blood with clots. Thereafter, he started actively bleeding with hypovolemic shock requiring massive transfusion protocol. CT angiography revealed a vascular blush in the left anterior wall of the anorectal junction. Flexible sigmoidoscopy showed active bleeding at the dentate line. The lesion was spurting bright red blood consistent with an arterial bleed. The mucosa around the lesion was normal. Hemostasis was achieved after injecting 5 mL of epinephrine. Due to the location of the lesion, no other endoscopic modalities were attempted. On the following day, bleeding recurred. Interventional radiology (IR) was not considered due to severe stenosis of the iliac vessels. The surgical team was consulted and proceeded with suture ligation of the bleeding arterial vessel. He remained stable with no recurrent episodes and was eventually discharged home. Unfortunately, he passed away three months later due to advanced malignancy. DISCUSSION: DLs are rare but well-recognized cause of GIB. They represent 6% of nonvariceal GIB. The incidence is probably underestimated given the diagnostic challenges. Only a few cases in the literature described anal DL. Occasionally, GIB from DL can be life-threatening. Reported mortality rate is 5%. Pathophysiology is not well established but theories include mucosal ischemia, mucosal atrophy, use of NSAIDs and arterial thromboses. Options of intervention include endoscopy (preferred), radiology and surgery. Endoscopic interventions can be subclassified into regional injection, thermal or mechanical. Endoscopic approach improves mortality and the need for surgical intervention. Recurrence occurs in 9–40% of cases. In our patient, due to the location of the lesion, decision was to avoid using thermal and/or mechanical modalities. Ultimately, hemostasis was achieved via surgical ligation of the vessel. In such cases, we recommend a multidisciplinary team approach including GI, surgery and IR to coordinate appropriate management.Figure 1.: Endoscopic Imaging revealing a bleeding Anal Dieulafoy Lesion.Figure 2.: Endoscopic Imaging revealing a bleeding Anal Dieulafoy Lesion.Figure 3.: Endoscopic Imaging revealing an Anal Dieulafoy Lesion after achieving Hemostasis.