Dieulafoy's Lesion of the Duodenum: A Rare and Fatal Cause of Gastrointestinal Bleed

Abstract

Dieulafoy's lesion (DL) is an unusual cause of recurrent gastrointestinal bleeding that can be fatal. It can occur in various parts of the gastrointestinal (GI) tract, most commonly located in the stomach, especially at the level of lesser curvature; however, it can occur in other parts, including the colon, esophagus, and duodenum. A duodenal Dieulafoy lesion is characterized by the presence of a larger-caliber artery that protrudes through the GI mucosa and can lead to massive hemorrhage. The exact cause of DL is yet to be determined. Clinical presentation includes painless upper GI bleeding, including melena, hematochezia, and hematemesis, or rarely iron deficiency anemia (IDA); however, most of the patients are asymptomatic. Some patients also have non-gastrointestinal comorbidities such as hypertension, diabetes, and chronic kidney disease (CKD). The diagnosis is established by esophagogastroduodenoscopy (EGD), which includes the presence of micro pulsatile streaming from a mucosal defect, the appearance of a fresh, densely adherent clot with a narrow point of attachment to a minute mucosal defect, and the visualization of a protruding vessel with or without bleeding. Initial EGD can be non-diagnostic due to the relatively small size of the lesion. Other diagnostic modalities include endoscopic ultrasound and mesenteric angiography. The treatment of duodenal DL includes thermal electrocoagulation, local epinephrine injection, sclerotherapy, banding, and hemoclipping. We present here a case of a 71-year-old female who had a history of severe IDA requiring multiple blood transfusions and intravenous iron in the past and was found to have duodenal DL.

Keywords: acute gastrointestinal bleeding; dieulafoy’s ulcer; duodenal dieulafoy’s disease; extragastric dieulafoy's lesion; extragastric location of dieulafoy's lesion.

Figure 1. Duodenal Dieulafoy lesion in the second part of the duodenum.

Figure 2. Successful clipping of the duodenal Dieulafoy lesion.