Diulafoy's Lesion - An Uncanny Etiology of Gastrointestinal Bleed.

Abstract

Introduction: Dieulafoy's lesion is a relatively rare, but potentially life-threatening, condition. It accounts for 1-2 percent of acute gastrointestinal (GI); bleeding.

Case: A 99-year-old woman was initially admitted due to left lower extremity cellulitis related to chronic venous stasis ulcer and was receiving broad-spectrum IV antibiotics. Upon admission to the medical floor, she had an episode of hematemesis and multiple bowel movements with black-tarry stools. The patient denied chronic non-steroidal anti-inflammatory drug use. Her past medical history was significant for dyslipidemia and remote history of colon cancer status post colon resection. Home medications included atorvastatin 20 mg and aspirin 81 mg. Digital rectal exam demonstrated melenic stool in the rectal vault. Hemoglobin and hematocrit on admission were noted to be 12.1 g/dl and 40.7 percent respectively which dropped to 8.1 g/dl and 28.3 percent following her GI bleed. A rise on BUN was also noted from 14 mg/dl to 34 mg/dl. Platelets and INR were normal. She received fluid resuscitation with 2 liters of crystalloid and a total of 2 units of pack red blood cells. Emergent EGD revealed a protruding and oozing vessel surrounded by normal gastric mucosa located at the greater curvature of the stomach body. The lesion was covered by a prominent fresh clot, which was cleared. Endoscopic hemostasis was achieved with a combination of epinephrine injection followed by BI-CAP electrocautery. The patient had an uncomplicated post-operative course and hemoglobin remained stable.

Discussion: Given this patient's clinical presentation, an upper GI bleed was suspected. Based on the patient's advanced age and history of previous history of colon cancer, the initial differential diagnosis included peptic ulcer disease versus a GI malignancy. However, her EGD findings were consistent with a Dieulafoy's lesion. Dieulafoy's lesions are twice as common in men as compared to women. These lesions can occur in any age group are diagnosed more frequently in the elderly population. Dieulafoy's lesions should be included in the differential diagnosis of obscure GI bleeding in all age groups.