A Rare Cause of Recurrent Lower Gastrointestinal Bleed: Colonic Dieulafoy’s Lesion

Abstract

Dieulafoy's lesion accounts for 1%-2% of acute gastrointestinal (GI) bleeding cases, and approximately 2% of Dieulafoy's lesions are present in the colon. We report the case of an 83-year-old female who presented with recurrent gastrointestinal bleeding from colonic Dieulafoy's lesion located at the hepatic flexure. She initially presented four weeks prior with melena in the setting of Eliquis use for venous thrombosis, coronary artery disease, and end-stage renal disease. Upper endoscopy revealed esophagitis, gastritis, and duodenitis. Diagnostic colonoscopy and video capsule endoscopy both revealed blood in the colon without an identifiable source. During the second admission for recurrent melena with hemoglobin of 3.9 g/dL, Eliquis was discontinued, and the patient was resuscitated with three units of packed red blood cell transfusions. Repeat colonoscopy revealed a pulsating vessel with active oozing located at the hepatic flexure, consistent with a Dieulafoy's lesion. Hemostatic endoclips and bipolar electrocautery were applied to achieve complete hemostasis. Colonic Dieulafoy's lesions, albeit rare, should be considered in patients presenting with an acute obscure lower GI bleed. Primary hemostasis can be achieved with several endoscopic modalities including epinephrine, hemoclipping, thermocoagulation, or sclerotherapy.

Dieulafoy Lesion of the Colon: A Rare Finding During Colonoscopy

“…The proposed pathophysiologic mechanism of a Dieulafoy lesion includes microtrauma and ischemia of overlying mucosa, subsequently leading to thinning of the mucosal wall, making it highly vulnerable to erosion and hemorrhage [ 7 ]. Clinical presentation varies from mild bleeding episodes to massive hemorrhage, with an increased risk with comorbidities like hypertension, cardiovascular disease, and chronic kidney disease with or without anticoagulation use [ 1 ]. Constipation or cancer also poses a significant risk for colonic Dieulafoy lesion due to mechanical factors [ 7 ].…”

“…A Dieulafoy lesion is defined as an aberrant dilated submucosal artery that erodes the overlying mucosal barrier without any mucosal ulceration [ 1 , 2 ]. First explained by Gallard in 1884 and named by a French surgeon Dieulafoy in 1898, they are responsible for 1-2% of acute gastrointestinal (GI) bleeding and can cause significant morbidity and mortality [ 1 - 4 ]. In the GI tract, they are mostly found in the stomach (70%) and the esophagus (15%).…”

“…In the GI tract, they are mostly found in the stomach (70%) and the esophagus (15%). With only 2% prevalence in the colon, Dieulafoy lesions are a very rare cause of lower GI bleeding as compared to more common causes like hemorrhoids, angiodysplasia, and diverticulosis [ 1 - 3 ]. Due to their small size and caliber, they are very difficult to diagnose endoscopically and can pose a diagnostic challenge [ 5 ].…”