Massive hemorrhage from a Dieulafoy lesion in the cecum: successful endoscopic management

Cecal Dieulafoy lesion is a rare cause of lower gastrointestinal bleeding: A case report

Dieulafoy lesions are a rare but life-threatening cause of gastrointestinal bleeding. Colonic Dieulafoy lesions are exceptionally rare, comprising only 2% of these lesions. We present a case of cecal Dieulafoy lesion as an unusual cause of lower gastrointestinal bleeding-along with hemoptysis. An 81-year-old male with pulmonary hypertension presented with a one-day history of hematochezia. He subsequently developed new small-volume hemoptysis/hematemesis with increasing oxygen requirements. Bronchoscopy revealed old blood in the left lower lobe, with no active bleeding. The hemoptysis was attributed to severe pulmonary hypertension. Colonoscopy revealed a 2-mm cecal Dieulafoy lesion with spurting bleeding, which was clipped. We report a rare case of cecal Dieulafoy lesion with only 13 other published cases. Our case was complicated by hemoptysis creating an interesting diagnostic dilemma. In patients bleeding from both oral and anal orifices, a brisk upper gastrointestinal bleed-as well as independent causes involving the gastrointestinal and respiratory tracts-should be considered.

Colonic Dieulafoy's Lesion: A Rare Cause of Lower Gastrointestinal Hemorrhage and Review of Endoscopic Management

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.

Rectal dieulafoy lesion managed by hemostatic clips

The classic Dieulafoy lesion is a minute gastric mucosal defect which bleeds massively from an exposed artery. The typical endoscopic appearance of this lesion is a single, round mucosal defect with an artery protruding from its base in the absence of surrounding ulceration. We encountered an 89-year-old man who developed sudden massive fresh rectal bleeding. The source of hemorrhage was found at colonoscopy after careful irrigation and inspection to be a Dieulafoy lesion situated in rectum. Hemostasis was achieved successfully with epinephrine injection and endoscopic hemostatic clipping.

Endoscopic clipping in the lower gastrointestinal tract

Endoscopic clipping has been established as a safe and effective method for the treatment of nonvariceal upper gastrointestinal bleeding in numerous randomized studies. Recently, clipping has been applied to various lesions in the lower gastrointestinal tract, including diverticular bleeding, postpolypectomy bleeding, and repair of perforations with successful outcomes. We review the safety and efficacy of this maneuver for the management of diseases in the lower gastrointestinal tract.

The use of endoclips in the treatment of nonvariceal gastrointestinal bleeding

Acute nonvariceal gastrointestinal bleeding is the most common emergency managed by endoscopists and the endoscopic therapy has generally been recommended as the first-line treatment. Traditionally, endoscopic treatment included injections of epinephrine and sclerosing solutions or the use of thermocoagulation. In the last decade with the introduction of hemoclips and band ligators, we have witnessed a significant improvement in the clinical outcome of nonvariceal gastrointestinal bleeding. Endoclipping is a safe and effective technique that contributes to hemostasis of bleeding lesions of the gastrointestinal tract.

[Lower gastrointestinal bleeding due to Dieulafoy's in the upper colon]

Dieulafoy's lesion is a vascular anomaly generally located in the proximal stomach, although it has also been documented in other areas such as the colorectum. It is mainly found in men aged between 50 and 70 years, and represents less than 2% of acute gastrointestinal hemorrhagic episodes.A 66-year-old woman who was undergoing oral Diclofenac treatment presented with black stools. Endoscopy revealed acute duodenal erosions with no signs of bleeding. Black stools persisted after Diclofenac was discontinued and omeprazole treatment was started and the patient was admitted to hospital after 7 days. Colonoscopy revealed active bleeding in the upper colon, which ceased after sclerosis with ethanolamine oleate. The patient was discharged from hospital but was readmitted 10 days later because of rebleeding. The results of upper endoscopy were normal and colonoscopy performed 3 days later detected neither lesions nor bleeding. The pathogenesis of Dieulafoy's lesion is not well known, although it could be caused by erosion of the mucous lining of a vessel. Definitive diagnosis is histologic, although certain endoscopic diagnostic signs have been described. Endoscopic diagnosis is sometimes difficult; in such cases, arteriography should be employed, both for diagnostic and therapeutic purposes. The treatment of choice is endoscopic and the use of two hemostatic methods is advisable. If these procedures fail, surgery is required. Arteriography is the most suitable alternative in patients who are poor candidates for surgery.

Lower intestinal bleeding

Lower gastrointestinal tract bleeding is a frequent cause of physician consultations and hospital admissions. Clinical presentation is predictable and significantly influences subsequent patient management. Controversy surrounding diagnosis and treatment of lower gastrointestinal bleeding results from a surprising lack of prospective controlled data. Thus, selection of diagnostic and therapeutic manoeuvres often depends more on local expertise and availability than on an algorithm approach. Advances in endoscopic, radiological and surgical equipment and techniques offer promising new diagnostic and therapeutic modalities, particularly in concerted applications. Outcome studies on the appropriate sequence and linking of these modalities are urgently needed. The present chapter will address clinical presentation, aetiology, diagnosis and treatment of lower gastrointestinal tract bleeding.