Dieulafoy’s Lesion in the Anal Canal: A Rare Cause of Massive Gastointestinal Hemorrhage

Abstract

Dieulafoy lezyonu nadir görülmesine rağmen alt gastrointestinal sistem kanamalarının hayatı tehdit eden nedenlerindendir. Masif alt gastrointestinal kanamaya ve mortaliteye neden olan anal kanaldaki Dieulafoy lezyonunu sunmayı amaçladık. Yetmiş iki yaşındaki erkek hasta masif kanama nedeniyle hastaneye başvurmuştur. Kolonoskopi ve sintigrafide odak saptanamadığından, unstabil durumda olan hastaya acil olarak laparotomi yapılmıştır. İntraoperatif olarak yapılan kolonoskopide anal kanal proksimalinde lezyon saptanarak klipslenmiştir. Kanama tekrarlamamasına rağmen, masif transfüzyona bağlı solunum problemleri nedeniyle postoperatif sekizinci günde hasta eksitus olmuştur. Bu tür lezyonlarda %80'e kadar varan oranlarda lezyon ilişkili mortalite oranları bildirilmiştir. Acil şartlarda yapılan bu değerlendirmelerde lezyon görülememiştir. Nadir karşılaşılsa da masif gastrointestinal kanamalarda Dieulafoy lezyonunun akılda tutulması gerekmektedir. Tedavide selektif arteriyel embolizasyon, skleroterapi, epinefrin enjeksiyonu, termokoagülasyon ve klipsleme gibi konservatif yöntemler kullanılabilir. Kanama odağının preoperatif dönemde bulunamadığı durumlarda lokalizasyon için cerrahi sırasında kolonoskopiden faydalanılabilir. Tanıda gecikme olan durumlarda kanama kontrol altına alınsa da masif transfüzyonlara bağlı morbiditenin ve mortalitenin artabileceği unutulmamalıdır. Anahtar Kelimeler: Anal kanal, kan transfüzyonu, kolonoskopi, Dieulafoy lezyonu, kanama, cerrahi ÖZ ABSTRACTDieulafoy's lesion is rare but life-threatening cause of lower gastrointestinal hemorrhage. In this study it is aimed to present a case of Dieulafoy lesion in anal canal which causes massive lower gastrointestinal hemorrhage and mortality. A 72 year-old male patient with massive lower gastrointestinal bleeding applied to the hospital. Since no lesion was detected on colonoscopy and scintigraphy, emergency laparotomy was performed for the unstable patient. On the intraoperative colonoscopy, a lesion was located proximal to anal canal and clipped. Despite the absence of rebleeding, the patient died due to respiratory complications associated with massive transfusion at the eighth day of his postoperation. For this kind of lesions, mortality rates were reported as up to 80%. In this case, the lesion was not found on evaluation performed under emergency setting. Although it is rare, Dieulafoy lesion should be kept in mind in patients with massive lower gastrointestinal hemorrhage. For treatment, conservative methods such as selective arterial embolisation, sclerotherapy, epinephrine injection, thermocoagulation and clips application can be used. When the location of bleeding was not revealed in preoperative evaluation, colonoscopy can be used during surgery. In case of delayed diagnosis the hemorrhage may be kept under control; however, morbidity and mortality may increase with massive transfusion.

Dieulafoy lesion in a Hartmann stump

“…In the literature, endoscopy was the most frequently used diagnostic method for RDL, although multiple examinations are required; also, diagnostic methods such as surgery, angiography, scintigraphy, tomography, and their combinations were mentioned. 8,9 In short, it is difficult to diagnose an RDL, and more than one diagnostic attempt may be necessary. 9 Although endoscopy is the most successful diagnostic tool, it may be unsuitable for providing treatment because of the hemorrhagic content in the rectum.…”

“…8,9 In short, it is difficult to diagnose an RDL, and more than one diagnostic attempt may be necessary. 9 Although endoscopy is the most successful diagnostic tool, it may be unsuitable for providing treatment because of the hemorrhagic content in the rectum. In our case, the source of the bleed was sutured by the transanal approach.…”

“…In the literature, endoscopic methods (eg, epinephrine injection, band ligation, sclerotherapy, and cauterization), surgical suturing, and angiographic embolization were all used in the treatment of RDLs. 9 However, no information demonstrated the superiority of one method over the others. It has been reported that patients with RDL may experience early recurrence after treatment, 10 but no recurrence was detected in our patient after18 months of follow-up.…”

“…However, the bleeding originated in the rectum, and RDL was diagnosed by colonoscopy. In the literature, endoscopy was the most frequently used diagnostic method for RDL, although multiple examinations are required; also, diagnostic methods such as surgery, angiography, scintigraphy, tomography, and their combinations were mentioned . In short, it is difficult to diagnose an RDL, and more than one diagnostic attempt may be necessary …”

“…In our case, the source of the bleed was sutured by the transanal approach. In the literature, endoscopic methods (eg, epinephrine injection, band ligation, sclerotherapy, and cauterization), surgical suturing, and angiographic embolization were all used in the treatment of RDLs . However, no information demonstrated the superiority of one method over the others.…”