Recurrent Gastrointestinal Hemorrhage From a Pair of Colonic Dieulafoy Lesions

Colonic dieulafoy lesions (DL) are rare and difficult to identify on colonoscopy. Diagnosis and therapeutic intervention of these lesions can result in resolution of gastrointestinal bleeding. We present a case of a transfusion-dependent patient with a past medical history of small bowel arteriovenous malformations that was found to have two DLs in her ascending colon. To our knowledge this is the first reported case of two actively bleeding colonic dieulafoy lesions. A 67-year-old female with a past medical history of chronic kidney disease on dialysis and arteriovenous malformations (AVMs) presented to the emergency department with weakness, loose dark stools and transfusion-dependent iron deficiency anemia. She reported a 2-3 day history of four dark loose stools per day. She denied abdominal pain, hematemesis or hematochezia. She reported taking iron pills and denied use of antiplatelets, anticoagulation or NSAIDs. This was her fourth admission for similar complaints over the last two months. While waiting for outpatient colonoscopy, she reported requiring two units of packed red blood cells (pRBC) at dialysis for Hg of 8. However, when it was noted at 6.2, she was sent for inpatient evaluation. A single balloon enteroscopy was negative and subsequent colonoscopy was significant for bright red blood was seen throughout the colon. Two lesions were identified in the ascending colon (IMAGE 1-2) and were determined to be DLs as there was no surrounding ulceration, erythema or evidence of inflammation. The lesions were treated with four endoclips each and the patient's hemoglobin stabilized over the next forty-eight hours. She was discharged home with close outpatient follow-up. Dieulafoy lesions (DL) account for an estimated 1-2% of gastrointestinal hemorrhage. The lesion can be defined as a small submucosal artery that protrudes through a two to five millimeter defect without surrounding ulceration or inflammation. Due to the subtle appearance of these lesions, it is one of the most difficult causes of GI bleeding diagnose. Patients often present with dramatic hematemesis, melena, hematochezia or a combination of the three. Most lesions occur in the stomach (71%) followed by the duodenum (15%) and colon (2%). Colonic lesions are challenging to identify via endoscopy however when found, therapeutic endoscopy can control the bleeding in 90% of patients. Angiography is used as an alternative to treat those that cannot be identified by endoscopy.1963_A Figure 1 No Caption available.1963_B Figure 2 No Caption available.