ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI An Unusual Cause of Torrential Lower Gastrointestinal Hemorrhage Terence C. Chua,1,2 Anthony J. Gill,3,4 and Jaswinder S. Samra1,2 1
Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia; 2Discipline of Surgery, University of Sydney, Sydney, New South Wales, Australia; 3Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia; and 4Diagnosis and Pathology Research Group, Kolling Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
Question: An 84-year-old man presented to the emergency department with 1 episode of large volume rectal bleed. He has a medical history that includes paroxysmal atrial fibrillation, diabetes mellitus, ischemic heart disease, and hypertension for which he takes metformin, insulin, digoxin, pantoprazole, simvastatin, aspirin, and betamin. On initial examination, he was afebrile with a systolic blood pressure (SBP) of 110, pulse rate of 110 and had a SBP postural decrease of 30 mmHg. Gastrointestinal examination revealed generalized pallor, dry mucous membranes, and a soft abdomen with no tenderness or masses on palpation. There was fresh blood and clots on rectal examination. Fluid resuscitation was initiated and his initial hemoglobin returned at 66 g/L with an International Normalized Ratio of 1.09. Two units of pack cells were transfused and a CT mesenteric angiogram was organized. What are the likely causes of a torrential lower gastrointestinal bleed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.10.046
Gastroenterology 2015;148:e10–e11
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 5: Dieulafoy Lesion
CT identified an arterial blush in a dilated segment of distal ileum that could present a Meckel’s diverticulum (Figure A). There were no other areas of bleeding identified. The patient was transferred to the operating room and underwent an emergency laparotomy. After exploration and examination of the small intestine from the ileocecal junction to the duodenojejunal flexure, there was no Meckel’s found. Given the CT findings, intraoperative isolated ileal enteroscopy was performed from 45 cm proximally to the ileocecal junction. This led to the identification of the bleeding site and a limited ileal resection was performed with side-to-side stapled anastomosis. The specimen was opened intraoperatively, revealing a bleeding site with surface clot and mucosal irregularity overlying only a subtle area of mucosal irregularity (Figure B, C). Pathologic examination revealed only a small area of ulceration at the base of which there was a large caliber artery (Figure D). A Dieulafoy lesion is owing to a histologically normal muscular artery that maintains an inappropriately broad caliber in the superficial submucosa, where it may lead to massive bleeding through only a small mucosal defect. It accounts for 1% of major gastrointestinal bleeds and is located commonly in the upper gastrointestinal tract.1 Its occurrence is rarely described in the ileum. This case depicts a standardized pathway in managing lower gastrointestinal hemorrhage with angiographic determination of the bleeding site. An endoscopic approach with application of resolution clips have been described in its management2; however, this was not attempted in this situation because the patient was unstable hemodynamically and the colon would have expectantly been filled with clots, rendering an endoscopic navigation unsafe. The resected ileum confirmed the diagnosis both intraoperatively and histologically.
References 1. 2.
Dieulafoy G. Exulceratio simplex: leçons 1–3. Clinique Médicale de l’Hotel Dieu de Paris 1898;2:1–38. Choi YC, Park SH, Bang BW, et al. Two cases of ileal Dieulafoy lesion with massive hematochezia treated by single balloon enteroscopy. Clin Endosc 2012;45:440–443.
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Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia; 2Discipline of Surgery, University of Sydney, Sydney, New South Wales, Australia; 3Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia; and 4Diagnosis and Pathology Research Group, Kolling Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
Question: An 84-year-old man presented to the emergency department with 1 episode of large volume rectal bleed. He has a medical history that includes paroxysmal atrial fibrillation, diabetes mellitus, ischemic heart disease, and hypertension for which he takes metformin, insulin, digoxin, pantoprazole, simvastatin, aspirin, and betamin. On initial examination, he was afebrile with a systolic blood pressure (SBP) of 110, pulse rate of 110 and had a SBP postural decrease of 30 mmHg. Gastrointestinal examination revealed generalized pallor, dry mucous membranes, and a soft abdomen with no tenderness or masses on palpation. There was fresh blood and clots on rectal examination. Fluid resuscitation was initiated and his initial hemoglobin returned at 66 g/L with an International Normalized Ratio of 1.09. Two units of pack cells were transfused and a CT mesenteric angiogram was organized. What are the likely causes of a torrential lower gastrointestinal bleed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.10.046
Gastroenterology 2015;148:e10–e11
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 5: Dieulafoy Lesion
CT identified an arterial blush in a dilated segment of distal ileum that could present a Meckel’s diverticulum (Figure A). There were no other areas of bleeding identified. The patient was transferred to the operating room and underwent an emergency laparotomy. After exploration and examination of the small intestine from the ileocecal junction to the duodenojejunal flexure, there was no Meckel’s found. Given the CT findings, intraoperative isolated ileal enteroscopy was performed from 45 cm proximally to the ileocecal junction. This led to the identification of the bleeding site and a limited ileal resection was performed with side-to-side stapled anastomosis. The specimen was opened intraoperatively, revealing a bleeding site with surface clot and mucosal irregularity overlying only a subtle area of mucosal irregularity (Figure B, C). Pathologic examination revealed only a small area of ulceration at the base of which there was a large caliber artery (Figure D). A Dieulafoy lesion is owing to a histologically normal muscular artery that maintains an inappropriately broad caliber in the superficial submucosa, where it may lead to massive bleeding through only a small mucosal defect. It accounts for 1% of major gastrointestinal bleeds and is located commonly in the upper gastrointestinal tract.1 Its occurrence is rarely described in the ileum. This case depicts a standardized pathway in managing lower gastrointestinal hemorrhage with angiographic determination of the bleeding site. An endoscopic approach with application of resolution clips have been described in its management2; however, this was not attempted in this situation because the patient was unstable hemodynamically and the colon would have expectantly been filled with clots, rendering an endoscopic navigation unsafe. The resected ileum confirmed the diagnosis both intraoperatively and histologically.
References 1. 2.
Dieulafoy G. Exulceratio simplex: leçons 1–3. Clinique Médicale de l’Hotel Dieu de Paris 1898;2:1–38. Choi YC, Park SH, Bang BW, et al. Two cases of ileal Dieulafoy lesion with massive hematochezia treated by single balloon enteroscopy. Clin Endosc 2012;45:440–443.
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