Korean J Gastroenterol.  2012 Oct;60(4):253-257. 10.4166/kjg.2012.60.4.253.

Massive Life-threatening Lower Gastrointestinal Hemorrhage Caused by an Internal Hemorrhoid in a Patient Receiving Antiplatelet Therapy: A Case Report

• Kim M
• Song HJ
• Kim S
• Cho YK
• Kim HU
• Song BC
• Chang WY
• Kim SH

• KMID: 1775810
• DOI: http://doi.org/10.4166/kjg.2012.60.4.253

Abstract

A Dieulafoy lesion in the rectum is a very rare and it can cause massive lower gastrointestinal bleeding. An 83-year-old man visited our hospital. He had chronic constipation and had taken aspirin for about 10 years because of a previous brain infarction. He was admitted because of a recent brain stroke. On the third hospital day, he had massive hematochezia and suddenly developed hypovolemic shock. Abdominal computed tomography showed active arterial bleeding on the left side of the mid-rectum. Emergency sigmoidoscopy showed an exposed vessel with blood spurting from the rectal wall. The active bleeding was controlled successfully by an injection of epinephrine and two hemoclippings. On the fourth day after the procedure, he had massive recurrent hematochezia, and his vital signs were unstable. Doppler-guided hemorrhoidal artery band ligation was performed urgently at two sites. However, he rebled on the third postoperative day. Selective inferior mesenteric angiography revealed an arterial pseudoaneurysm in a branch of the superior rectal artery, as the cause of rectal bleeding, and this was embolized successfully. We report a rare case of life-threatening rectal bleeding caused by a Dieulafoy lesion combined with pseudoaneurysm of the superior rectal artery which was treated successfully with embolization.

Keyword

Gastrointestinal hemorrhage; Dieulafoy lesion; Aneurysm, false; Therapeutic embolization

MeSH Terms

Aged, 80 and over
Aneurysm/radiography
Angiography
Aspirin/therapeutic use
Brain Infarction/drug therapy/prevention & control
Embolization, Therapeutic
Gastrointestinal Hemorrhage/*diagnosis/etiology/therapy
Hemorrhoids/*complications
Humans
Male
Mesenteric Artery, Inferior/radiography
Platelet Aggregation Inhibitors/therapeutic use
Rectal Diseases/complications/diagnosis/therapy
Rectum/blood supply
Sigmoidoscopy
Tomography, X-Ray Computed

Figure

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  Fig. 1 Abdominal pelvic CT findings (enhanced image). Contrast-enhanced axial (A) and coronal (B) CT images showing contrast extravasation from the left side wall of the mid-rectum (arrows), which was suggestive of active arterial bleeding.

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  Fig. 2 Endoscopic findings. (A) Emergency sigmoidoscopy showed an exposed vessel with blood spurting from the rectal wall with an internal hemorrhoid. (B) The active bleeding was controlled successfully after injection of epinephrine and two hemoclippings. (C) On the next day, follow-up sigmoidoscopy showed multiple stercoral ulcers with internal hemorrhoid but no further bleeding.

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  Fig. 3 Angiographic findings. Selective inferior mesenteric arteriography revealed an arterial pseudoaneurysm (A) in a branch of the superior rectal artery, which was the cause of the massive rectal bleeding. It was embolized successfully by superselective embolization with n-butyl cyanoacrylate (Histoacryl®), a permanent embolic agent (B).

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