S2186 Colonic Dieulafoy's Lesion: A Rare Presentation of Lower GI Bleeding

Abstract

INTRODUCTION: Dieulafoy's lesions (DL) are rare (1–2%) causes of gastrointestinal bleeding. Colonic DLs are even rarer (∼2%) cause of lower GI bleeding.Early recognition of this entity is important given its infrequent occurrence, and yet, potentially life-threatening outcome. CASE DESCRIPTION/METHODS: A 64-year-old male with HFrEF, CKD and A- Fib on Eliquis 5 mg BID and Aspirin 81 mg presented to ER with 6-week history of melena with a hemoglobin of 7.4 g/dL on admission, BP of 95/55 mmHg, pulse of 65 bpm and an oxygen saturation of 98% on 2 L O2. Abdominal examination was unremarkable. His INR was 1.3. He received 3 units of pRBC. EGD was negative. Colonoscopy performed thereafter revealed fresh blood throughout the entire colon and a pulsatile, non spurting, briskly bleeding artery in mid transverse colon. Successful hemostasis was achieved with 2 clips (Figure 1) and injection of epinephrine (1:10,000). A tattoo was placed near the lesion. He denied ongoing rectal bleeding but continued to have dark solid stools on iron supplements for chronic anemia. Follow-up colonoscopy pursued 4 months later to perform polypectomy showed a similar arterial type bleeding vessel in proximal ascending colon and was completely ablated with Argon Plasma Coagulation at 0.8 L/min flow and 20 max Watts (Figure 2). The patient was sent home on continued iron replacement, and advised to resume Elliquis the next day; and is doing well presently. DISCUSSION: DL is a normal vessel with an abnormally large diameter maintaining a constant width of 1-3 mm as it runs a tortuous course within the submucosa and typically protrudes through a small (2-5mm) mucosal defect with basal fibrinoid necrosis. DLs are mostly found in stomach (71%, 85% on lesser curvature). Colonic DLs account for 2% of cases of lower GI bleeding. Typically, patients are elderly male with cardiopulmonary and renal dysfunction, often are on antiplatelet or anticoagulant agents (AP/AC) and presents with acute, intermittent, and clinically significant melena, hematochezia, or symptoms of shock. Exact pathogenesis of spontaneous rupture is unknown but mucosal ischemia or erosion from ageing, arteriolar pulsation, cardiovascular disease, AP/AC agents and stercoral injury may unmask the silent anomaly. GI endoscopy is preferred in diagnosis and successful management (>90%) of DLs as in our patient while embolization and surgery are reserved for refractory cases.Figure 1.: Colonoscopic view of an actively bleeding Dieulafoy's lesion in transverse colon (left) and subsequent hemostasis with clips and epinephrine (right).Figure 2.: Colonoscopic view of an actively bleeding Dieulafoy's lesion in ascending colon (left) and subsequent hemostasis with argon plasma coagulation(right).