Successful side-viewing endoscopic hemoclipping for Dieulafoy-like lesion at the brim of a periampullary diverticulum

Abstract

Background: Duodenal Dieulafoy's lesions are rare and only several cases were reported so far. Their characteristic appearance and location make it difficult to be diagnosed in the clinical practice. Massive bleeding often results from these lesions and can impede the accurate early treatment.

Case presentation: 67 years old male patient suffered a fatal bleeding from Dieulafoy-like lesion located at the mouth of the periampullary diverticulum. Initial endoscopic therapy and radiologic embolization failed to stop the bleeding, while direct observation and hemoclipping by the side viewing endoscopy successfully established correct diagnosis and permanent cure of the lesion.

Conclusion: Aggressive endoscopic examinations combined with the accurate endoscopic treatment should be adopted when Dieulafoy-like lesion is suspected as a possible cause of the proximal small bowel hemorrhage. Verification of the diagnosis and definitive treatment often needed repeated examination by side-viewing endoscope as well as stabilization of the patient.

Figure 1

Initial manifestation and treatment. A. On duodenoscopic exam, at the margin of large(about 6 cm) periampullary diverticulum was a small exposed vascular turft emanating the spurting jet of blood. B. Epinephrine and saline mixture was injected to lessen the bleeding, but complete hemostasis was not achieved.

Figure 2

Radiologic intervention. A. On celiac axis angiogram, a extravasation of the contrast media from the distal branch of gastroduodenal artery was noted. B. The branch was superselected and embolized with microcoils.

Figure 3

Rebleeding and final endoscopic hemostasis. A. After angiographic intervention failed, duodenoscopic examination revealed constant bleeding B. Two metalic hemoclips were successfully placed through the side-viewing endoscope at the Dieulafoy-like lesion and instant hemostasis was achieved.

Figure 4

Short and long term outcome. A. 3 days later, hemoclips were seen securely placed at the lesion. No recurrent bleeding occurred. B. 2 months later, hemoclips were gotten rid of spontaneously leaving only faint scar.