Endoscopic band ligation for the treatment of rectal Dieulafoy lesions: risks and disadvantages

A Dieulafoy lesion is an uncommon vascular abnormality that can cause life-threatening gastrointestinal bleeding. It is becoming increasingly apparent that these lesions, although usually gastric, can develop throughout the gastrointestinal tract. Dieulafoy lesions in the colon, first described by Barbier et al. [1], are most frequently found in the proximal colon and the rectum [2]. With the advent of therapeutic endoscopic techniques, endoscopic therapy has become the treatment of choice for this lesion for many endoscopists, and this type of management has been proved to be effective in the majority of cases. However, there is limited information available on the endoscopic treatment of extragastric Dieulafoy lesions. There have only been a few small case series due to the rarity of the lesion. Yen & Chen [3] described the risks and disadvantages of endoscopic band ligation (EBL) for the treatment of Dieulafoy lesions. A case of delayed fatal hemorrhage after EBL treatment of a gastric Dieulafoy lesion has also been reported [4]. It is therefore clear that EBL has some disadvantages, particularly in the treatment of extragastric Dieulafoy lesions.

The last six patients admitted to our hospital with acute lower gastrointestinal bleeding due to a rectal Dieulafoy lesion were treated with bipolar electrocoagulation, hemoclipping, and band ligation. Of the four patients who were treated with band ligation ([Fig. 1], [2]), two experienced recurrent bleeding (on day 3 and on day 5) after the EBL ([Table 1]). Successful hemostasis was not achieved by additional injection and hemoclipping, and suture ligations of the vessel were performed transanally. Based on our own experience, we would like to briefly review the current thinking on this procedure and discuss the endoscopic treatment of bleeding rectal Dieulafoy lesions.

Fig. 1 A rectal Dieulafoy lesion.

Fig. 2 A Dieulafoy lesion of the rectum, after one band ligature was placed on the bleeding vessel, with necrotic ulcer formation.

Table 1 Demographic, clinical, and endoscopic characteristics of six patients with a bleeding rectal Dieulafoy lesion who were initially treated endoscopically Patient Sex Age, years Co-morbid conditions Endoscopic stigmata Hemostasis Recurrence of bleeding Retreatment Complications Follow-up, months 1 F 77 Hypertension Protruding vessel EBL × 1 No - None 18 2 F 78 Chronic renal failure Protruding vessel with active bleeding HSE injection and EBL × 2 Yes Suture ligation None 10 3 F 85 Hypertension Protruding vessel EBL × 1 Yes Suture ligation None 6 4 M 61 Chronic renal failure Protruding vessel with active bleeding EBL × 2 No - None 7 5 F 42 None Protruding vessel HSE injection and hemoclipping No - None 20 6 M 61 None Protruding vessel HSE injection and bipolar electrocoagulation No - None 16 EBL, endoscopic band ligation; HSE, hypertonic saline epinephrine.

Several treatment methods for Dieulafoy lesions have been described, but endoscopic treatment is currently considered to be the treatment of choice. Successful hemostasis can be achieved by endoscopic treatment in more than 90 % of patients [2]. Of the endoscopic treatments available, mechanical methods (hemoclipping and band ligation) have shown good results for initial hemostasis and long-term outcome, mainly for lesions located in the upper gastrointestinal tract [5]. However, assessment of the mechanical methods for treating colonic Dieulafoy lesions is anecdotal because of the low incidence of this abnormality. Abdulian et al. [6], who treated a bleeding rectal lesion with epinephrine injection, first described successful endoscopic therapy of a Dieulafoy lesion in this site. Meister et al. [7] reported five patients whose rectal Dieulafoy lesions were successfully treated with combined injection and heater-probe coagulation methods. There have been only a few patients who have been diagnosed with colonic Dieulafoy lesion in whom mechanical treatment methods have been reported.

Endoscopic band ligation is technically easier to perform than other treatment modalities; the lesions are easily viewed under direct pressure and suction from the transparent ligation cap. However, the band ligation can be complicated by recurrent bleeding due to ulcer formation, perforation, delay in overtube preparation, technical difficulties (particularly in retroflexion), and the lack of availability of local expertise [8]. In our cases, it is possible that significant rebleeding might have occurred because the ligature was not being placed entirely around the bleeding vessel. However, we believe that the rebleeding in our cases was mainly due to ulcer formation.

Our patients with recurrent bleeding had co-morbid illnesses such as chronic renal failure. In critically ill patients with severe gastrointestinal bleeding, endoscopic hemoclipping has been shown to be an effective alternative treatment [9]. Gimeno-Garcia et al. [10] reported two patients who were treated with a combined endoscopic approach, with hemoclips and an endoloop. Hemoclipping, coagulation, and other combination methods might be alternatives to band ligation; the success of these alternative methods for the prevention of rebleeding can be confirmed by Doppler ultrasound.

In summary, our results suggest that band ligation has some risks and disadvantages, associated with rebleeding. Further studies are needed to determine the best approach for the definitive treatment of patients with bleeding rectal Dieulafoy lesions.

Competing interests: None

References

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