Dieulafoy’s lesions are a rare cause of gastrointestinal hemorrhage. Extragastric Dieulafoy’s lesions are even more uncommon. We report the case of a 75-year-old woman who presented with gastrointestinal bleeding from a transverse colonic Dieulafoy’s lesion. She presented with two episodes of melena followed by one episode of fresh blood per rectum. In addition, there was associated presyncope and anemia (hemoglobin 69 g/L) in the setting of supratherapeutic warfarin anticoagulation (INR 6.2) for nonvalvular atrial fibrillation. Esophagogastroduodenoscopy was negative for an upper GI source of bleeding but on colonoscopy an actively oozing Dieulafoy’s lesion was identified in the transverse colon. Bipolar cautery and hemostatic endoclips were applied to achieve hemostasis. Clinicians should consider this rare entity as a potential cause of potentially life-threatening lower gastrointestinal bleeding and we review the endoscopic modalities effective for managing colonic Dieulafoy’s lesions.
Dieulafoy’s lesions (also known as caliber persistent artery, submucosal arterial malformation, or solitary exulceration simplex) are an uncommon cause of gastrointestinal hemorrhage. They are defined by a dilated aberrant submucosal vessel that does not undergo normal distal branching or tapering and subsequently protrudes through a minute defect in the overlying mucosa but without primary mucosal ulceration [
Here, we present the case of a 75-year-old woman who developed a lower gastrointestinal bleed secondary to a transverse colonic Dieulafoy’s lesion. This case highlights the importance of both careful endoscopic evaluation in investigating gastrointestinal hemorrhage and consideration of rare entities in the differential diagnosis of common clinical presentations. Finally, we review the literature of diagnostic and therapeutic measures previously utilized for identifying and managing colonic Dieulafoy’s lesions.
A 75-year-old female presented to hospital with two episodes of melena followed by one episode of moderate volume bright red blood per rectum. She had multiple medical comorbidities including coronary artery disease with previous ST-elevation myocardial infarction complicated by congestive heart failure, diabetes, hypertension, and gastroesophageal reflux disease. She was also known to be in persistent atrial fibrillation, complicated by tachy-brady syndrome requiring pacemaker insertion in 2012 and ongoing anticoagulation with warfarin.
The patient had no previous history of gastrointestinal hemorrhage prior to presentation. Associated with the bleeding, she endorsed presyncopal symptoms but was hemodynamically stable and denied hematemesis. There was no associated nausea, vomiting, diarrhea, or abdominal pain. Initial examination found a benign, nontender, nonperitonitic, nondistended abdomen and rectal examination demonstrated residual melena stool. Initial investigations were significant for severe anemia, with hemoglobin of 69 g/L (baseline hemoglobin > 100 g/L from one year prior), and supratherapeutic warfarin anticoagulation with international normalized ratio (INR) of 6.2. In the emergency department, the patient was supportively managed with intravenous crystalloid fluid and two units of packed red blood cell transfusion. Her anticoagulation was reversed with intravenous vitamin K and transfusion of one unit of fresh frozen plasma.
Esophagogastroduodenoscopy was normal with no evidence of active bleeding. However, on ileocolonoscopy, a large overlying fresh blood clot was visualized in the transverse colon. After disruption of the clot with irrigation, an actively oozing Dieulafoy’s lesion was visualized (Figure
Presence of active oozing blood from transverse colonic Dieulafoy’s lesion. Arrow indicates source of bleeding.
Application of bipolar cautery using 7-French probe to colonic Dieulafoy’s lesion.
Application of hemostatic endoclip to colonic Dieulafoy’s lesion after bipolar cautery, achieving hemostasis.
First reported in 1985 by Barbier et al. [
Dieulafoy’s lesions typically present with painless large volume bleeding, making them clinically difficult to distinguish from other causes of lower gastrointestinal bleeding such as arteriovenous malformations or diverticular hemorrhage. As with our case, bleeding risk is increased in patients with medical comorbidities such as hypertension or cardiovascular disease and in patients on concurrent anticoagulation [
Although capable of presenting with massive hemorrhage, Dieulafoy’s lesions can be challenging to diagnose. In the era before readily available colonoscopy, direct mesenteric angiography was often required for localization of bleeding [
Management of colonic Dieulafoy’s lesions has evolved to become predominantly endoscopic. Early reported cases were treated surgically with partial colectomy, primarily in the setting of uncontrollable, life-threatening, lower gastrointestinal hemorrhage [
As with gastric Dieulafoy’s lesions, rebleeding has been described from colonic sites. Although repeated endoscopic measures have been utilized, rescue therapy with angiographic embolization [
In conclusion, although rare, colonic Dieulafoy’s lesions can be a cause of life-threatening hemorrhage that should be considered in the differential diagnosis of lower gastrointestinal bleeding. They are important to recognize as they can be effectively managed using a number of endoscopic techniques, including epinephrine injection, clipping, or thermocoagulation.
The paper was submitted as abstract to ACG Annual Conference 2014.
The authors have no conflict of interests to declare.