Shiva Kumar, MD, MS, FASGE from the Center for Liver Disease & Transplantation, Aurora St. Luke’s Medical Center, Milwaukee, Wisconsin and the Digestive Disease Institute, Cleveland Clinic, Abu Dhabi, Abu Dhabi, UAE reports on this video case, “Colonic Dieulafoy’s lesion.”
An 85-year-old male presented with transfusion dependent anemia secondary to recurrent episodes of rectal bleeding. Given significant underlying cardiac co-morbidity and ongoing antiplatelet therapy, it was imperative that a bleeding source be identified and treated effectively. The fact that a moderate amount of fresh blood and clots was seen in the distal descending colon, sigmoid and rectum during colonoscopy, with an unremarkable proximal colon, implied that the bleeding source was located in the left colon. There were no obvious sources of bleeding such as diverticulosis, hemorrhoids, mucosal inflammation/ injury or angioectasias. This mandated a careful search for more obscure sources of distal colonic blood loss.
Meticulous examination of the left colon revealed a source of brisk blood loss in the sigmoid. We concluded that this represented a colonic Dieulafoy’s lesion given lack of associated mucosal ulceration or lesion. The lesion was then treated with a combination of argon plasma coagulation and hemoclip application, resulting in immediate and lasting hemostasis despite continued anti-platelet therapy.
I felt that this video would serve an important role to highlight an uncommon, but often under-recognized cause of recurrent lower gastrointestinal blood loss. Dieulafoy’s lesion is most often identified as a source of bleeding in the stomach or proximal duodenum. First reported in 1985 by Barbier et al, colonic Dieulafoy’s lesions are an uncommon cause of lower gastrointestinal bleeding. In a recent comprehensive review of all reported cases by Baxter et al, only 2% of Dieulafoy’s lesions were noted to be in the colon. However it is essential that endoscopists be aware of the possibility of this entity in the colon, since the lack of associated visible mucosal changes and the episodic nature of bleeding makes this a challenging entity to diagnose and treat. Accurate characterization is essential to ensure appropriate endoscopic therapy, which is usually very effective in this setting, thereby obviating the need for consideration of angiographic embolization or surgery.
I also felt that this video could serve the purpose of highlighting therapeutic options that are available to the endoscopist to effectively treat a colonic Dieulafoy’s lesion after it is recognized. Endoscopic therapy of a Colonic Dieulafoy’s lesion is often more challenging than those in the stomach or proximal duodenum, given the tortuosity of the sigmoid and difficulty in maintaining appropriate endoscope position. I utilized argon plasma coagulation as an adjunct, primarily to mark the site for clipping given the brisk nature of the bleeding and the location of the bleeding site in a tortuous sigmoid colon. Endoscopic application of hemoclips is generally the most effective approach in this setting. Endoscopic cap-assisted hemostasis could be used alternatively. Other reported modalities include epinephrine injection, thermocoagulation and sclerotherapy. This case underscores the fact that appropriate endoscopic treatment can result in complete resolution of gastrointestinal bleeding from a Dieulafoy’s lesion.
In summary, I hope that this video would increase awareness among endoscopists to the possibility of Colonic Dieulafoy’s lesion as a potential cause of recurrent, unexplained lower gastrointestinal bleeding and highlight available endoscopic therapeutic options.
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