Mystery Bleed: A Case Report of a Rectal Dieulafoy Lesion

Introduction: Dieulafoy Lesions (DL), typically found on upper endoscopy, is a rare cause of lower gastrointestinal (GI) bleeding. They are identified as the etiology of lower GI bleeding in 0.09% of diagnostic colonoscopies. We present a case of massive lower GI bleeding secondary to a rectal Dieulafoy Lesion. Case Description/Methods: A 56-year-old male with past medical history of uncontrolled type 2 diabetes mellitus was admitted to the hospital with lower extremity cellulitis. He was treated with antibiotics and surgical debridement and kept on his home aspirin as well as 5000 units of subcutaneous heparin for thrombosis prophylaxis. He suddenly complained of a large amount of rectal bleeding. Labs revealed hemoglobin (Hb) 8 g/dl (from baseline of 9 g/dl), HCT 25.8, MCV 82.8, white blood cell count 14, platelets 381, PT 9.8, INR 0.9, aPTT 18.8. Upper/lower endoscopies were performed, and an active bleeding site was not identified. Patient underwent tagged red blood cell(RBC) scan which was non revealing and was transfused 2 units of packed RBC. The following day, the patient had another episode of massive bright red blood per rectum with clots. Vitals remained stable however, Hb dropped to 7.1 g/L, and one unit of PRBC was transfused. Repeat urgent tagged RBC scintigraphy suggested a gastric source of bleeding. Repeat upper endoscopy was negative for bleeding. Urgent flexible sigmoidoscopy was performed and during slow withdrawal, a spurting artery was noted 5 cm proximal to the anal verge on the posterior rectal wall and an 8 mm DL was visualized. 5 ml of 1:10,000 epinephrine was injected to slow the bleeding and a 12/6 atraumatic over the scope clip was successfully deployed achieving hemostasis. 48 hours post procedure the patient’s Hb remained stable and did not require further blood transfusion. Discussion: Lower GI DL is rare but associated with high mortality due to delay in diagnosis. It causes rapid blood loss since it is arterial, and diagnosis of such lesions may be challenging. The mainstay management for DL is endoscopically controlling the bleeding after adequate hemodynamic resuscitation and stabilization. In our case we managed the DL with epinephrine injection and clipping.Figure 1.: The colonscopy images for the rectal Dieulafoy lesion A :the vessel for DL B :bleeding from the DL C :before clipping after epinephrine injection D : DL lesion after clipping.