1682 Jejunal Dieulafoy's Lesion

Abstract

INTRODUCTION: Dieulafoy’s lesions (DLs) comprise 2% of acute gastrointestinal bleeds and are most commonly found in the stomach, though 3.5% of DLs occur in the small bowel. Jejunal DLs pose unique diagnostic and treatment challenges due to low incidence and the absence of standardized therapy. We present a case of acute, symptomatic anemia secondary to a jejunal DL. CASE DESCRIPTION/METHODS: A 64-year-old Hispanic woman with no significant past medical history presented with symptomatic anemia after three days of melena. She was hemodynamically stable with palpable internal hemorrhoids and brown stool on digital rectal exam. Her hemoglobin was 4.8 g/dL and responded to transfusion. Bidirectional endoscopy found antral erosions without stigmata of bleeding, small hemorrhoids, and dark stool throughout the colon. Capsule endoscopy revealed bright red blood at 23% progress through the small bowel. Subsequent anterograde single-balloon enteroscopy demonstrated an actively spurting DL in the mid-jejunum. Hemostasis was achieved with epinephrine injection and bipolar diathermy. The patient was followed for six months without evidence of re-bleeding. DISCUSSION: DLs are non-inflammatory, solitary mucosal defects with protrusion of an aberrant artery. Jejunal DLs comprise 1% of all DLs. Diagnosis is made endoscopically, but lesions are often unrecognized due to small size and preservation of surrounding mucosa. As such, multiple endoscopies are often required to reach a diagnosis. Initial endoscopy and colonoscopy are followed by capsule endoscopy in hemodynamically stable patients with suspicion of a mid-gastrointestinal bleed. Further approach with single or double balloon enteroscopy is preferred for the evaluation of jejunal DLs. With the expansion of endoscopic techniques, endoscopy has replaced surgery as first line treatment for small bowel DLs. However, there is no current standard endoscopic therapy, given that there is limited data directly comparing modalities for jejunal DLs. For general DLs, mechanical therapy is superior to either thermal or injection therapy. For ulcerative diseases, the use of two endoscopic techniques is superior to a single technique, alone. Thus, it has been suggested that the optimal treatment for jejunal DLs utilizes two endoscopic modalities, with one being mechanical, though further research is needed. Watch the video: http://bit.ly/2YZE0Zj.