S2355 An Unusual Presentation of a Rare Cause of Lower Gastrointestinal Bleeding: Cecal Dieulafoy’s Lesion Presenting as Melena

Abstract

Introduction: Dieulafoy’s lesion is characterized as a large tortuous submucosal artery projecting through a small mucosal defect with no evidence of primary mucosal ulceration or erosion. These lesions are uncommonly identified as causes of acute gastrointestinal (GI) bleeding, accounting for only 1-2% of cases. Dieulafoy’s lesions can occur throughout the entire GI tract, most commonly occurring in the stomach (72% of cases) and rarely in the lower GI tract (5% of cases). Typically, lower GI tract Dieulafoy’s lesions present as hematochezia. We report an unusual case of a cecal Dieulafoy’s lesion that presented as melena. Case Description/Methods: A 64-year-old male with a relevant past medical history of hypertension, rheumatoid arthritis (on chronic steroids) and superior vena cava thrombosis (on anticoagulation) presented with melena. The patient denied bright red blood per rectum, or any other gastrointestinal symptoms. His vital signs were stable at the time of presentation. Physical examination was unremarkable except for melenic stool on rectal exam. Labs were significant for a hemoglobin of 7.0 g/dL (prior baseline of 12.0 g/dL), AST 67 U/L, ALT 43 U/L, ALP 219 U/L, INR 1.17, and PTT 55.3 seconds. Due to evidence of persistent bleeding, three units of packed red blood cells were transfused and a pantoprazole drip was initiated with suspicion of an upper GI source of bleed. Endoscopy was performed, which showed esophagitis with no active bleeding and gastritis. A colonoscopy was then performed which revealed a solitary Dieulafoy’s lesion in the cecum. An overlaying adherent clot was dislodged to reveal the lesion. Complete hemostasis was achieved using four hemostatic clips. Post procedural course was uncomplicated and the patient’s hemoglobin remained stable. Discussion: Our case describes a cecal Dieulafoy’s lesion that presented, unusually, as melena. There have been several reports of cecal Dieulafoy’s lesion presenting as hematochezia. To our knowledge, this is the first reported case of a cecal Dieulafoy’s lesion presenting solely as melena. We aim to add to the relatively few cases of cecal Dieulafoy’s reported, and help improve the diagnostic accuracy of these type of lesions. Without timely diagnosis and treatment, Dieulafoy’s lesions have the potential to progress to life-threatening bleeding. Thankfully, with expedient diagnosis and with modern endoscopic tools, hemostasis can be achieved in up to 90% of such cases.Figure 1.: A: Bleeding cecal Dieulafoy’s lesion B: Endoscopic clip removing adherent clot and exposing visible vessel C: Hemostasis achieved with four hemostatic clips.