Rectal Dieulafoy Research Articles

S3799 An Unexpected Case of Lower GI Bleeding From a Rectal Dieulafoy Lesion

S3799 An Unexpected Case of Lower GI Bleeding From a Rectal Dieulafoy Lesion

A Rare Cause of Lower Gastrointestinal Bleeding: Rectal Dieulafoy’s Lesion

Dieulafoy’s lesion is rare cause of life-threatening gastrointestinal bleeding. Mortality is high if not early diagnosed and treated properly. Thus, it must be excluded and treated in patients with GIB as fast as possible. These lesions are usually observed in upper gastrointestinal system and mostly in the stomach. It is very rare in rectum. Here we report a rare case of lower gastrointestinal bleeding caused by rectal Dieulafoy’s lesion.

Successful hemostasis with red dichromatic imaging for bleeding rectal dieulafoy's lesion.

Successful hemostasis with red dichromatic imaging for bleeding rectal dieulafoy's lesion.

S3002 Rectal Dieulafoy Lesion: A Rare Finding with Deadly Consequences

S3002 Rectal Dieulafoy Lesion: A Rare Finding with Deadly Consequences

S2640 Rectal Dieulafoy's Lesion Presenting as Massive Hematochezia With a Characteristic Endoscopic Appearance

S2640 Rectal Dieulafoy's Lesion Presenting as Massive Hematochezia With a Characteristic Endoscopic Appearance

Delayed-onset bleeding after transrectal prostate biopsy presenting as a rectal Dieulafoy's lesion.

Delayed-onset bleeding after transrectal prostate biopsy presenting as a rectal Dieulafoy's lesion.

Rectal Dieulafoy's lesion: a comprehensive review of patient characteristics, presentation patterns, diagnosis, management, and clinical outcomes.

Dieulafoy's lesion is an abnormally large, tortuous, submucosal vessel that erodes the overlying mucosa, without primary ulceration or erosion. Although these lesions predominantly involve the stomach and upper small intestine, they are being detected with increasing frequency in the rectum. We conducted a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases for adult rectal Dieulafoy's lesion. After careful review of the search results, a total of 101 cases were identified. The data on patient characteristics, clinical features, colonoscopy findings, diagnosis, treatment, and clinical outcomes were collected and analyzed. The mean age of presentation was 66±17 years (range, 18-94 years), with 54% of cases reported in males. Clinical presentation was dominated by acute lower gastrointestinal bleeding in the form of bright-red blood per rectum 47% and hematochezia 36%, whereas 16% of patients were admitted with symptoms related to other medical conditions. Major underlying disorders were hypertension 29%, diabetes mellitus 21%, and chronic kidney disease 16%. The average number of colonoscopies required for the diagnosis of rectal Dieulafoy's lesion was 1.5±0.7. In regard to treatment, endoscopic therapy was applied in 80%, direct surgical suturing in 12%, angiographic embolization in 4%, and endoscopic therapy followed by surgical ligation was performed in 4% of patients. The endoscopic treatment was a feasible choice for rectal disease, with a primary hemostasis rate of 88%. Although the overall mortality rate was 6%, the causes of death were unrelated to this entity. This review illustrates that patients with rectal Dieulafoy's lesion can have a favorable clinical outcome. Prompt diagnosis and appropriate management are of paramount importance to prevent serious hemodynamic complications. The best therapeutic modality remains to be determined but the data presented here support the use of mechanical endoscopic methods as safe and effective.

S687 Efficacy of Endoscopic Treatment in Patients With Rectal Dieulafoy's Lesion: A Systematic Review

S687 Efficacy of Endoscopic Treatment in Patients With Rectal Dieulafoy's Lesion: A Systematic Review

Endoscopic band ligation for a rectal Dieulafoy's lesion.

Endoscopic band ligation for a rectal Dieulafoy's lesion.

3131 Rectal Dieulafoy's Lesion: A Rare Cause of Massive Lower GI Bleed

INTRODUCTION: Dieulafoy's lesions can be a life-threatening source of gastrointestinal bleeding. While most commonly seen in the stomach, they have been described throughout the GI tract, including the rectum. These lesions consist of a persistent caliber, submucosal artery that can be difficult to identify on endoscopic evaluation. Rectal Dieulafoy's lesions are a rare source of lower GI bleeding that can present with large volume hematochezia requiring prompt management. Two cases of bleeding secondary to a rectal Dieulafoy's lesion are reviewed. CASE DESCRIPTION/METHODS: Case 1: A 94-year-old man with multiple cardiompulmonary comorbidities presented initially for sepsis secondary to osteomyelitis and developed hematochezia during admission. Hgb went from 10.0 g/dL to 7.1 g/dL, but he remained hemodynamically stable and bleeding self-resolved. Colonoscopy was deferred due to patient preference. The patient was readmitted to the hospital 8 days later with continued hematochezia and found to have Hgb 6.3 g/dL. Colonoscopy showed a visible Dieulafoy's lesion that was injected with 2 mL 1:10,000 epinephrine and then treated with 2 hemostatic clips. After intervention, bleeding resolved. Case 2: A 91-year-old man with a history of dementia and COPD was admitted for two days of hematochezia. On admission, he was transiently hypotensive with a SBP in the 50s and a Hgb of 9.4 g/dL with a baseline of 13-14 g/dL. Hgb eventually reached a nadir of 7.4 g/dL. Flexible sigmoidoscopy showed a visible Dieulafoy's lesion. Three hemostatic clips were placed in setting of active oozing with control of bleeding. DISCUSSION: Dieulafoy's lesions were first described in 1884 and are now more commonly described given advances in endoscopy. These lesions account for only 1-2% of GI bleeds, however this number may be underrepresented due to the difficulty of diagnosis. The rectum is involved in only about 2% of cases of Dieulafoy's lesions. The etiology of these lesions is unclear, but likely have some relationship to age, co-morbidities, and NSAID use. Endoscopy is the main method of diagnosis, though EUS, VCE, or angiography are also useful. Hemostasis is usually achieved through thermal therapy, injection with epinephrine, or banding/hemoclip with dual modality being preferred. The cases above represent two examples of a rectal Dieulafoy's lesion, a rare etiology of lower GI bleeding. Management of these bleeds requires prompt evaluation with endoscopy and can be successfully treated via multiple modalities.

1988 Rectal Dieulafoy's Lesion: Hemorrhagic Shock Due to a Rare Cause of Acute Lower GI Bleeding

INTRODUCTION: Dieulafoy's lesions account for 1–2% of acute GI bleeding and are characterized by dilated aberrant submucosal vessels that erode the overlying epithelium in the absence of a primary ulcer. While the majority are found in the stomach (71%), they occur along other parts of the GI tract, however rectal sites are rare and only account for 1–2%. We present a case of massive LGIB due to a rectal Dieulafoy's lesion in a patient with intermittent hematochezia. CASE DESCRIPTION/METHODS: A 58-year-old female presenting with DKA had a hospital course complicated by necrotizing pneumonia requiring VATS and trach/PEG placement. Early in her admission she developed hematochezia with Hgb drop of 9.3 to 6.4 (baseline 12–13). EGD was unremarkable. Colonoscopy revealed a 1.5 cm clean based rectal ulcer that did not require intervention. 2 weeks later recurrent hematochezia presumably from rectal tube responded conservatively with TXA soaked Merocel packing. Hematochezia re-occurred 10 days later in the setting of a gradual drop in Hgb over the previous 2 weeks requiring 3u PRBCs(11.7 to 6.7 to 8.5). The following day she had large volume hematochezia with clots and was pale, diaphoretic, and less responsive with BP of 60/45, HR of 122 and Hgb of 5.8. Resuscitative efforts included IVF bolus, 4u PRBCs, 1u platelets, 2u FFP and pressor support. Patient continued to have active passage of multiple blood clots and after bedside evaluation we elected to proceed with emergent bedside EGD/colonoscopy after 1 tap water enema. Initially CTA was considered due to the rapidity of her bleed and significant hemodynamic compromise, however patient developed AKI and was too unstable for transport. EGD was normal and colonoscopy revealed large amounts of blood in rectum, sigmoid and descending colon with brown stool proximal to splenic flexure and normal TI. The colon was irrigated and revealed a large clot in distal rectum which was injected with Epi and then removed, revealing normal mucosa. Continued irrigation revealed blushing and after careful endoscopic inspection an actively spurting small vessel was seen protruding through rectal mucosa without surrounding ulcer suggestive of a Dieulafoy's lesion. Three clips deployed with good hemostasis and site tattooed. Hgb remained stable and no recurrence of bleeding during hospitalization. DISCUSSION: This case highlights the importance of vigilance in the evaluation of recurrent LGIB with timely resuscitative and endoscopic measures in identifying a rare source of massive LGIB.

Endoscopic management of massive rectal bleeding from a Dieulafoy's lesion: Case report.

BACKGROUNDRectal Dieulafoy's lesions (DLs) are very rare; however, they can be life threatening when presented with massive hemorrhage.CASE SUMMARYA 44-year-old female with medical history of chronic renal failure who was on renal replacement therapy presented with lower gastrointestinal hemorrhage. Physical examination revealed signs of hypovolemic shock and massive rectal bleeding. Complete blood count revealed abrupt decrease in hematocrit. After hemodynamic stabilization, an urgent colonoscopy was performed. A rectal DL was diagnosed, and it was successfully treated with two hemoclips. There were no signs of recurrent bleeding at thirty days of follow-up.CONCLUSIONRectal DLs represent an unusual cause of lower gastrointestinal bleeding. Massive hemorrhage can increase the morbidity and mortality of these patients. Endoscopic management continues to be the reference standard in the diagnosis and therapy of these lesions. Thermal, mechanical (hemoclip or band ligation), or combination therapy (adrenaline injection combined with thermal or mechanical therapy) should be considered the first choice for treatment.

Dieulafoy Lesion of the Rectum

Dieulafoy's lesion (DL) is a well-recognized cause of upper gastrointestinal bleeding (GIB). DL is a dilated, aberrant, submucosal, arterial vessel usually located in the proximal stomach and duodenum. It accounts for less than five percent of cases of GIB, but can cause massive, life-threatening bleeding due to its arterial nature. The etiology of DL is unknown. Common comorbidities includes cardiovascular disease, kidney disease, diabetes, alcohol abuse and chronic NSAIDs use. The most common diagnostic and treatment modality is endoscopy. Refractory cases can be treated with arterial embolization, and uncontrollable hemorrhage may be treated with emergent resection. We present the case of a patient with life-threatening, massive lower GIB from DL in the rectum. A 59 year old female with a history of microcytic anemia, diabetes, hypertension, was admitted to the Intensive Care Unit with Goodpasture disease (GD) resulting in respiratory and renal failure. She received cyclophosphamide, prednisone, and plasmapheresis with improvement of her respiratory function, but without improvement in her kidney function. One month into admission the patient suffered a hemodynamically significant GIB requiring transfusion and admission to the ICU. Colonoscopy revealed a rectal ulcer and large fecalith. She was diagnosed with a stercoral ulcer. One week later, she was readmitted to the ICU in hemorrhagic shock and found to have a hemoglobin of 5.2 g/dl. Mesenteric arteriography showed active extravasation in the rectum. Temporary embolization using gel foam was performed which stopped active bleeding. Colonoscopy showed a single pulsatile visible artery protruding from the rectal mucosa, a DL, which was treated with injection of epinephrine and application of a single hemoclip. DL of the rectum is a very rare cause of massive GIB, described almost exclusively in case reports or case series. The pathophysiologic mechanism of these lesions is not well defined, but is thought to occur as a result of localized mucosal ischemic damage and acquired vascular ectasia which erodes through threatened mucosa. Our patient was treated with cyclophosphamide and steroids which may have contributed to poor mucosal healing predisposing her to a rectal DL. DL is often considered as a cause of upper GIB. This patient presented in hemorrhagic shock from a rectal DL causing a massive lower GIB.1931_A Figure 1. Mesenteric arteriography with contrast extravasation1931_B Figure 2. Endoscopic visualization of a rectal dieulafoy's lesion

Atypical appearance of a rectal Dieulafoy lesion

Atypical appearance of a rectal Dieulafoy lesion

Massive bleeding from a rectal Dieulafoy lesion in a patient with alcoholic cirrhosis

Massive bleeding from a rectal Dieulafoy lesion in a patient with alcoholic cirrhosis

Novel Treatment Approach for Rectal Dieulafoy Lesion With Over-The-Scope Clip (OTSC)

Novel Treatment Approach for Rectal Dieulafoy Lesion With Over-The-Scope Clip (OTSC)

Rectal Dieulafoy lesion

Rectal Dieulafoy lesion

A case of massive lower gastrointestinal bleeding from a rectal Dieulafoy lesion

Summary A Dieulafoy lesion is an uncommon and sometimes life-threatening cause of gastrointestinal hemorrhage. Typically, it presents as a tiny mucosal defect with an exposed protruding artery with normal surrounding mucosa. An 84-year-old woman developed sudden massive hematochezia and had an unstable hemodynamic status. The source of bleeding was found to be an exposed vessel in the rectum without surrounding ulceration. The patient was treated successfully with an epinephrine injection given endoscopically, followed by hemostatic clipping.

Endoscopic ultrasound-guided therapy of a rectal Dieulafoy lesion

Endoscopic ultrasound-guided therapy of a rectal Dieulafoy lesion

Endoscopic Management of Rectal Dieulafoy's Lesion: A Case Series and Optimal Treatment.

Rectal Dieulafoy's lesion (DL) is rare cause of lower gastrointestinal bleeding. Because of its rarity, there is no consensus on the optimal endoscopic hemostasis technique for rectal DL. We analyzed six patients who underwent endoscopic management for rectal DL after presenting with hematochezia at a single institute over 10 years. Of the six patients, three underwent endoscopic band ligation (EBL) and three underwent endoscopic hemoclip placement (EHP). Only one patient was treated with thermocoagulation. There were no immediate complications in any of the patients. None of the patients required a procedure or surgery for the treatment of rebleeding. Mean procedure times of EBL and EHP were 5.25 minutes and 7 minutes, respectively. Both EHP and EBL are shown to be effective in the treatment of bleeding rectal DL. We suggest that EBL may have potential as the preferred therapy owing to its superiority in technical and economic aspects, especially in elderly and high-risk patients.