Ischemic gastropathy is an uncommon diagnosis due to extensive arterial collaterals that supply the stomach. The mucosal integrity of the stomach is dependent upon this redundant circulation. Hence, its diagnosis is infrequently entertained in patients presenting with an upper gastrointestinal (GI) bleed. Herein, we report a case of a 76-year-old woman with hypertension, hyperlipidemia, and chronic kidney disease on dialysis who developed an upper GI bleed after becoming septic and hypotensive.

INTRODUCTION: Dieulafoy lesions involve a large-caliber, tortuous artery in the muscularis mucosa that protrudes due to a submucosal defect with fibrinoid necrosis at the base. The submucosal artery is found to have atypical branching and as a result has a diameter of 1-3 mm, which is 10 times that of a normal mucosal capillary. These lesions can be found throughout the gastrointestinal tract, though they are most frequently found in the stomach, ranging between 61 to 82%. However 10% of all gastrointestinal tract Dieulafoy lesions are found in the colon with 42% of these lesions found in the rectum. CASE DESCRIPTION/METHODS: A 79-year-old male with past medical history significant for prostate cancer, hypertension, gout, degenerative joint disease and alcohol abuse disorder presented with bilateral leg weakness and was admitted to the medical service for alcohol dependency and acute kidney injury. On day 12 of hospitalization, he developed melena with a drop in hemoglobin from 12.0 g/dL at the time of admission to 7.7 g/dL. He was then transferred to the critical care unit and underwent esophagogastroduodenoscopy that revealed angioectatic lesions that bled and were treated with argon photocoagulation. On day 15, he developed hematochezia, which further decreased his hemoglobin to 6.9 g/dL. He became hemodynamically unstable, requiring rapid fluid and blood resuscitation. Emergent CT angiography was concerning for vascular malformation in the rectal wall. Colonoscopy was performed and a stream of pulsatile bleeding without an ulcer or varix, consistent with a Dieulafoy lesion, was seen in the rectum. Epinephrine was applied, the lesion was clipped, and hemostasis was achieved. No repeat episodes of gastrointestinal bleeding were reported afterwards. DISCUSSION: Bleeding from Dieulafoy lesions can cause hemodynamic compromise as noted in this patient. Therefore prompt identification and treatment is warranted. Endoscopy serves as a gold standard for identification. Hemostasis has been achieved with many techniques in case reports including: BICAP cauterization; combined sclerotherapy and electrocoagulation; heater-probe coagulation; and epinephrine injection combined with electrocoagulation. Rebleeding rate ranges from 6 to 28%. Systemic reviews and retrospective analysis suggest that mechanical ligation to achieve hemostasis, especially the use of hemoclips, may be superior to other techniques employed.

Simultaneous liver abscesses are rarely seen and reported. We are reporting a case of two simultaneous, complex liver abscesses in a patient who had no evidence of liver abscess on cross-sectional imaging close to three months prior to this presentation. These abscesses were 7-8 cm in size, large, and septated. Microbiological studies were positive for Streptococcus constellatus, which is a known cause of pyogenic liver abscess. In our patient, pyogenic liver abscesses were associated with bacteremia and sepsis. This patient was managed with broad spectrum parenteral antibiotics and percutaneous drainage with improvement in clinical condition. This patient was discharged home with a peripherally inserted central catheter (PICC) line in place to complete a six-week course of parenteral antibiotics. A complete history and physical with pertinent examination findings are key to diagnosis of liver abscess. S. constellatus should be considered in the differential diagnosis of patients with liver abscess and sepsis.