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

Endoscopic Ultrasound-Guided Coil Embolization of Refractory Rectal Dieulafoy Bleeding

Hematochezia due to recurrent bleeding from rectal Dieulafoy can be challenging for endotherapy. We report the first case of successful endoscopic ultrasound-guided coil embolization of a feeding arteriole to the peripheral Dieulafoy vessels in the region of a colorectal anastomosis. The patient presented with recurrent lower gastrointestinal hemorrhage despite multiple previous conventional endoscopic treatment modalities.

Severe lower gastrointestinal bleeding caused by rectal Dieulafoy's lesion: Case reports and literature review

RATIONALE

Dieulafoy's lesion are relatively rare and can cause severe gastrointestinal bleeding. A Dieulafoy's lesion is defined as an artery that erodes the overlying epithelium without the presence of an ulcer. Bleeding in Dieulafoy's lesion predominantly involves the proximal stomach and upper gastrointestinal tract and is rarely observed in the lower gastrointestinal tract.

PATIENT CONCERNS

Case 1 was a 58-year-old woman complaining of sudden headache and vomiting who was diagnosed with subarachnoid hemorrhage. She underwent transcatheter embolization for intracranial aneurysm treatment but had an acute profuse hematochezia on the 11th day of admission. Case 2 was a 63-year-old man admitted to the respiratory intensive care unit because of fever with altered consciousness level for a week. He was diagnosed with advanced lung cancer that had metastasized to multiple organs one month prior. On the third day of admission, he had an attack of profuse hematochezia, and quickly developed shock and apathy.

DIAGNOSIS

Both patients were diagnosed with actively bleeding rectal Dieulafoy's lesion by bedside emergency colonoscopy.

INTERVENTIONS

Endoscopic hemostatic clipping was performed in 2 patients.

OUTCOMES

Hemostasis was successfully achieved in these 2 patients, and there was no recurrence of symptoms during follow-up.

CONCLUSIONS

We propose that hemostatic clipping is one of the options in the treatment of rectal Dieulafoy's lesions.

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.

Severe Gastrointestinal Bleed Caused by a Rectal Dieulafoy Lesion

Dieulafoy lesions are vessels that erode the overlying epithelium without the presence of an ulcer. When these lesions bleed, they can frequently be self-limited, but bleeding can be recurrent and prolonged. Although most commonly found in the lesser curvature of the proximal stomach, there are reports of these lesions in other gastrointestinal tract regions. This case identifies a Dieulafoy lesion found in the rectum, which was the source of this patient’s profuse rectal bleeding.

Jejunal Dieulafoy's Lesion: A Systematic Review of Evaluation, Diagnosis, and Management

Jejunal Dieulafoy's lesion is an exceedingly rare but important cause of gastrointestinal bleeding. It frequently presents as a diagnostic and therapeutic conundrum due to the rare occurrence, intermittent bleeding symptoms often requiring prompt clinical action, variability in the detection and treatment methods, and the risk of rebleeding. We performed a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases regarding jejunal Dieulafoy's lesio from inception till June 2020. A total of 136 cases were retrieved from 76 articles. The mean age was 55 ± 24 years, with 55% of cases reported in males. Patients commonly presented with melena (33%), obscure-overt gastrointestinal bleeding (29%), and hemodynamic compromise (20%). Hypertension (26%), prior gastrointestinal surgery (14%), and valvular heart disease (13%) were the major underlying disorders. Conventional endoscopy often failed but single- and double-balloon enteroscopy identified the lesion in 96% and 98% of patients, respectively. There was no consensus on the treatment. Endoscopic therapy was instituted in 64% of patients. Combination therapy (34%) with two or more endoscopic modalities, was the preferred approach. With regard to endoscopic monotherapy, hemoclipping (19%) and argon plasma coagulation (4%) were frequently employed procedures. Furthermore, direct surgical intervention in 32% and angiographic embolization was performed in 4% of patients. The rebleeding rate was 13.4%, with a mean follow-up duration of 17.6 ± 21.98 months. The overall mortality rate was 4.4%. Jejunal Dieulafoy's lesion is still difficult to diagnose and manage. Although the standard diagnostic and therapeutic modalities remain to be determined, device-assisted enteroscopy might yield promising outcomes.

Dieulafoy disease with gastric MALT lymphoma: A case report

RATIONALE

Dieulafoy lesion (DL), a rare cause of gastrointestinal bleeding, is easily covered by blood scab formation on the mucous membrane for its small size, which makes it difficult to be identified under endoscope. In clinical practice, it is also very easy to miss gastric mucosa-associated lymphoid tissue (MALT) lymphoma that exhibits atypical early manifestations under gastroendoscope and is difficult to be diagnosed by routine superficial biopsy. Most patients only experience nonspecific dyspepsia symptoms.

PATIENT CONCERNS

A 68-year-old man suffering from repeated melena for 6 years arrived at our hospital. The patient had undergone gastroscopy and capsule endoscopy at other hospitals for several times and received symptomatic treatment, but his melena still continued to recur. At our hospital, the capsule endoscopy displayed that there existed large hemorrhage in the stomach, after which a gastrointestinal decompression tube was placed, so the bright red blood was drained. Subsequently, a sunken vascular malformation tissue in the anterior wall of the gastric fundus was observed under emergency endoscope. Pulsating blood flow appeared immediately after biopsy, and over-the-scope clip (OTSC) was quickly applied to stop the bleeding. Near the bleeding point, scar-like tissue that was surrounded by interrupted mucosa was discovered, and biopsy was performed at this site.

DIAGNOSIS

The diagnosis of DL and gastric MALT were determined by the digestive endoscopy and biopsy pathology.

INTERVENTIONS

With the diagnosis of DL and gastric MALT, the hemorrhagic spot was treated by OTSC. After the patient's condition was stable, anti-Helicobacter pylori treatment was performed.

OUTCOMES

After the corresponding treatment, the 6-month follow-up revealed that the lymphoma was not completely cured, but no further bleeding occurred. There was no bleeding in the epigastric region and the patient was in good condition.

LESSONS

From endoscopy, it is easy to miss DL. When the hemostatic equipment is fully prepared, biopsy can be performed. After biopsy, pulsatile bleeding is convincing evidence for Dieulafoy disease. OTSC represents an effective and low-risk method for DL and it could replace surgery. Moreover, the mucosa surrounding Dieulafoy disease should be carefully observed to exclude coexisting diseases such as lymphoma or gastric cancer.