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.