Discussion:
Lower gastrointestinal bleeding (LGIB) is less common than upper
intestinal bleeding and can account for about 30% of major GI bleeding
that requires hospitalization [1].
Lower GI bleeding has a myriad of causes with common etiologies such as
diverticulosis, angioectasias, ischemic colitis, neoplasm, and
hemorrhoids [1]. However, there are less common causes, such as
Dieulafoy Lesions [1]. They account for about 2% of all acute GI
bleeds [3]. Dieulafoy lesions in the lower GI tract are rare,
accounting for approximately 5% of total cases [3]. There is a
higher predilection for males, and typically occurs after the 5th decade
[3].
Dieulafoy lesions are vascular malformations of the gastrointestinal
tract [2]. It is an enlarged submucosal blood vessel that can bleed
without the presence of ulcers or erosions [2]. Dieulafoy lesions
are believed to occur due to pulsations or an abnormally large artery
that could disrupt the mucosal lining, exposing the artery and causing
possible bleeding [2]. Arterial thrombosis can allow for necrosis of
the arterial wall, possibly causing rupture [3]. However, the risk
of bleeding can be enhanced by other factors, including the use of
NSAIDs, tobacco, alcohol, and peptic ulcer disease [2]. It is
possible that mucosal irritation by feces can also contribute to colonic
Dieulafoy lesions [3]. Typically found in the upper GI tract, it is
often found in the stomach [2]. Specifically seen in the lesser
curvature, within 6 cm of the gastroesophageal junction, given its
arterial blood supply from the branches of the left gastric artery
[2]. Extragastric lesions can occur; however, are rarer in
presentation [2]. In a study by Baxter et al., colonic sites were
reported in less than 2% of cases [4].
Upon endoscopic evaluation, the following criteria are necessary for
diagnosis: Normal mucosa around the defect, with active pulsatile
bleeding that is less than 3 mm [2]. A visualized protruding vessel
from a defect or normal mucosa [2]. A fresh clot attached to the
defect of normal mucosa is observed [2].
Treatment for Dieulafoy lesions is endoscopic intervention, with
mechanical hemostasis being the safest modality [2]. Banding
ligation and hemoclips are often utilized, and combined therapy is
superior relative to monotherapy[2]. Hemostasis is successful in
80-85% of cases treated with endoscopy [2]. Areas can be marked
with India ink for further identification if further intervention is
warranted [2]. However, if endoscopic treatment is not therapeutic,
surgical interventions such as wide wedge resection or partial/wedge
gastrectomy can be considered [2]. In our patient, hemostasis was
achieved via hemoclips and epinephrine injection and did not report any
further rebleeding.