E192 UCTN – Unusual cases and technical notes Treatment of Dieulafoy’s lesion of the right colon with epinephrine injection and argon plasma coagulation Dieulafoy’s lesion is a tiny submucosal J. L. S. Souza defect overlying an artery in the muscu- Department of Gastroenterology, laris mucosa [1]. Dieulafoy’s lesion of the Diagnostic Center in Gastroenterology, colon is a rare cause of lower gastrointes- University of Sao Paulo, Brazil tinal bleeding [2]. A 63-year-old woman with multiple mye- References loma underwent autologous bone mar- 1 Juler GL, Labitzke HG, Lamb R et al. The pa- row transplantation and after 6 weeks thogenesis of Dieulafoy’s gastric erosion. Am J Gastroenterol 1984; 79: 195 – 200 developed massive hematochezia with 2 Norton ID, Petersen BT, Sorbi D et al. Man- hemodynamic instability. Colonoscopy agement and long term prognosis of Dieula- demonstrated bright red blood in the foy lesion. Gastrointest Endosc 1999; 50: terminal ileum, all of the colon, and the 762 – 767 3 Suzuki N, Arebi N, Saunders BP. A novel rectum (l" Fig. 1). method of treating colonic angiodysplasia. After the area had been washed with wa- Fig. 1 Colonoscopy showing spurting active Gastrointest Endosc 2006; 64: 424– 427 ter, a point of spurting active bleeding bleeding in ascending colon. 4 Calvet X, Vergara M, Brullet E et al. Addition was located in the ascending colon. We of a second endoscopic treatment following injected epinephrine and the bleeding epinephrine injection improves outcome in high risk bleeding ulcers. Gastroenterology stopped; identification of a minute muco- 2004; 126: 441– 450 l" sal defect was then possible ( Fig. 2). 5 Chung IK, Kim EJ, Lee MS et al. Bleeding We complemented the treatment with Dieulafoy’s lesions and the choice of endo- argon plasma coagulation (APC) using a scopic method: comparing the hemostatic 2.3-mm probe, with flow rate of 1.0 L/ efficacy of mechanical and injection meth- ods. Gastrointest Endosc 2000; 52: 721– minute and a setting of 40 W in order to 724 minimize the risk of bowel perforation, until the lesion was completely coagul- Bibliography ated. Submucosal injection of epine- DOI 10.1055/s-0029-1214774 phrine has a protective effect when using Endoscopy 2009; 41: E192 thermal techniques in the right colon [3]. Georg Thieme Verlag KG Stuttgart · New York · There was no rebleeding during the fol- ISSN 0013-726X low-up of 14 days. The patient died after Fig. 2 Minute mucosal defect in ascending this period from septic shock. Corresponding author colon identified after injection of epinephrine. Dieulafoy’s lesion in the setting of hemor- J. L. S. de Souza, MD rhagic shock has a high risk of rebleeding, Department of Gastroenterology, Diagnostic Center in Gastroenterology, justifying the addition of a complemen- To our knowledge, this is the first report University of S¼o Paulo tary endoscopic treatment (thermal or of a combined endoscopic approach with 255 Dr EnØas de Carvalho Aguiar Ave. mechanical) following epinephrine injec- injection of epinephrine and APC to treat 9th floor – Room 9159 tion [4–5]. However, we have to keep in a Dieulafoy’s lesion of the right colon in a S¼o Paulo mind that the right colon has a thinner patient with significant thrombocytope- Brazil This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. wall compared with the stomach, and nia. It seems to be a secure and effective Fax: +55-11-30697940 use of band ligation and heat probe with modality of endoscopic therapy of bleed- [email protected] high temperatures can lead to bowel per- ing in this setting, with minimum risk of foration. perforation and high possibility of hemo- stasis. Endoscopy_UCTN_Code_CPL_1AH_2AB Souza JLS. Epinephrine injection and APC for Dieulafoy’s lesion … Endoscopy 2009; 41: E192.