INTRODUCTION: Dieulafoy's lesions account for 1–2% of acute GI bleeding and are characterized by dilated aberrant submucosal vessels that erode the overlying epithelium in the absence of a primary ulcer. While the majority are found in the stomach (71%), they occur along other parts of the GI tract, however rectal sites are rare and only account for 1–2%. We present a case of massive LGIB due to a rectal Dieulafoy's lesion in a patient with intermittent hematochezia. CASE DESCRIPTION/METHODS: A 58-year-old female presenting with DKA had a hospital course complicated by necrotizing pneumonia requiring VATS and trach/PEG placement. Early in her admission she developed hematochezia with Hgb drop of 9.3 to 6.4 (baseline 12–13). EGD was unremarkable. Colonoscopy revealed a 1.5 cm clean based rectal ulcer that did not require intervention. 2 weeks later recurrent hematochezia presumably from rectal tube responded conservatively with TXA soaked Merocel packing. Hematochezia re-occurred 10 days later in the setting of a gradual drop in Hgb over the previous 2 weeks requiring 3u PRBCs(11.7 to 6.7 to 8.5). The following day she had large volume hematochezia with clots and was pale, diaphoretic, and less responsive with BP of 60/45, HR of 122 and Hgb of 5.8. Resuscitative efforts included IVF bolus, 4u PRBCs, 1u platelets, 2u FFP and pressor support. Patient continued to have active passage of multiple blood clots and after bedside evaluation we elected to proceed with emergent bedside EGD/colonoscopy after 1 tap water enema. Initially CTA was considered due to the rapidity of her bleed and significant hemodynamic compromise, however patient developed AKI and was too unstable for transport. EGD was normal and colonoscopy revealed large amounts of blood in rectum, sigmoid and descending colon with brown stool proximal to splenic flexure and normal TI. The colon was irrigated and revealed a large clot in distal rectum which was injected with Epi and then removed, revealing normal mucosa. Continued irrigation revealed blushing and after careful endoscopic inspection an actively spurting small vessel was seen protruding through rectal mucosa without surrounding ulcer suggestive of a Dieulafoy's lesion. Three clips deployed with good hemostasis and site tattooed. Hgb remained stable and no recurrence of bleeding during hospitalization. DISCUSSION: This case highlights the importance of vigilance in the evaluation of recurrent LGIB with timely resuscitative and endoscopic measures in identifying a rare source of massive LGIB.
Figure 1. Sevelamer crystals are highlighted in (a), (b), and (c) with acute inflammation demonstrated in (c).
Introduction: Generally of pulmonary origin, small cell cancer is a locoregionally aggressive malignancy that can infrequently arise from the integumentary, upper respiratory, genitourinary, lymphatic, and gastrointestinal tracts. Rectal SCC (RSCC) is particularly rare, accounting for , 0.2% of large bowel cancer. Prognosis is dismal with a median survival of 6-12 months. Here we present a case of RSCC presenting as a rectal ulcer in a patient evaluated for hematochezia. Case Description/Methods: A 75-year-old male with atrial fibrillation on rivaroxaban and a remote history of prostate cancer status-post radiotherapy presented with 24 hours of hematochezia, rectal tenesmus, and diarrhea, but denied weight loss or abdominal pain. Hemoglobin trended from a baseline of 13.5 g/dL 5 months earlier to 11.9 g/dL upon presentation. Diagnostic colonoscopy revealed a firm 3 cm ulcerative rectal mass with heaped borders and friability 2 cm from the anal verge. Pelvic MRI showed the mass abutting the prostate without evidence of extension into adjacent tissues. Brain MRI was negative for intracranial metastasis, and whole-body PET CT showed abnormal uptake in the perirectal, posterior pelvic, right and left inguinal lymph nodes without intrathoracic uptake. Histopathological analysis revealed RSCC with strong CD56 expression, weak expression of synaptophysin and chromogranin, and absent CD45 expression. FNA of the right inguinal lymph node confirmed lymphatic spread, establishing a final staging of T3a-T4bN2aM0 (group IIIC). Given his history of prostate radiation, he was not a candidate for further radiotherapy. He was induced on etoposide/carboplatin and is being considered for either abdominoperineal resection or pelvic exenteration (Figure). Discussion: Colorectal cancer (CRC) is relatively common, with 151,030 new cases of large bowel cancer diagnosed annually in the United States, with 52,580 deaths per year. RSCC is often metastatic, portending a poor prognosis. Primary RSCC is particularly rare, though radiotherapy and chemotherapy can be an effective in neoadjuvant, adjuvant, and palliative contexts when combined with surgery. Though radiotherapy significantly increases survival in RSCC, our patient's close tumor proximity to his prostate cancer radiotherapy site precluded further radiotherapy. Overall, the prognosis for RSCC remains dismal, with mean relapse of 1 year, even in treated patients. Although rare, our case highlights how RSCC should remain on the differential for both CRC and hematochezia.[2106] Figure 1. Top Left: Rectal mass biopsy under hematoxylin-eosin stain shows dense clusters of oval or round cells (red arrows) with round or oval nuclei, high nuclear/cytoplasmic ratios, prominent mitoses, and conspicuous necrosis that are characteristic of small cell cancer. Bottom Left: Colonoscopy image of a large, ulcerative, friable rectal mass with heaped up borders unlike the typical appearance of adenocarcinoma, which more often presents with a polypoid mass or obstructing lesion. Right: PET-CT slice sho...
Figure 1. Esophageal Web pre dilation (a) and post dilation (b).
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