Granulomatous mastitis is a chronic inflammatory breast disease with an enigmatic clinical presentation that can delay diagnosis and perpetuate ineffective treatments. We report our experience with the diagnosis and management of eighteen cases of granulomatous mastitis in the setting of an urban public hospital. The patients were identified after a retrospective review of pathology and surgery databases. Demographic, clinical, radiographic, histopathological data and treatment responses were reviewed. Out of a total of 18 patients, 8 patients were noted to be from Mexico. The mean age at presentation was 35 years and 11 of the 18 patients reported a pregnancy in the last four years. Most cases were unsuccessfully managed as bacterial breast infections initially; definitive treatment involved surgical excision and steroids. A complete symptomatic and radiographic resolution was documented in 8 of the 18 patients. Despite posing a challenge for the unsuspecting physician, an early diagnosis of granulomatous mastitis improves patient outcomes.

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.