2003 Extragastric Dieulafoy’s Lesion: A Rare and Often Missed Cause of Upper Gastrointestinal Bleeding

Abstract

INTRODUCTION: Dieulafoy’s lesions (DL) are an important, potentially life threatening, cause of gastrointestinal (GI) bleeding. Dieulafoy’s lesions are dilated, aberrant, submucosal arteries that erode overlying GI mucosa in the absence of an underlying ulcer, aneurysm, or intrinsic mural abnormality. They account for approximately 1.5% of acute upper GI bleeding and 70% of these lesions are found within 6 cm of the gastroesophageal junction. Although uncommon, DL have been reported in the duodenum, distal stomach, and esophagus. We present a case describing the discovery and management of an extragastric DL within the duodenum. CASE DESCRIPTION/METHODS: An 83-year-old male with multiple comorbidities, on warfarin therapy, presented to the hospital by instruction of his primary care physician for evaluation of a low hemoglobin (Hgb). He has a history of chronic anemia with regularly monitored Hgb. The patient endorsed 4 days of painless, dark, loose stools. He reported a similar episode to this several years prior and underwent upper and lower endoscopy, which were unrevealing. Capsule endoscopy at that time did show a small bowel arteriovenous malformation, but otherwise unremarkable. On admission, the patient was hemodynamically stable with mild pallor noted on exam. Initial workup revealed Hgb of 6.8 g/dL and an INR of 3.1. Upper endoscopy was performed revealing a single spurting spot of active bleeding in the second part of the duodenum consistent with a DL. The area was successfully treated with epinephrine, coagulation, and hemostatic clips. He remained hospitalized for five days post-procedure for medical optimization. His Hgb remained stable and his warfarin was resumed. DISCUSSION: Dieulafoy’s lesions are a rare cause of upper GI bleeding that should always remain on the differential diagnosis. While gastric DL are well-known, there are few reports describing DL of the duodenum. The scarce nature of their occurrence make these lesions difficult to diagnose. Thorough endoscopic evaluation is usually the first diagnostic test performed for acute upper GI bleeding. Thus, this is the primary modality used for the diagnosis of DL. Initial EGD is diagnostic in only about 70% of cases due to relatively small lesion size, intermittently active bleeding, and lesion location. This case represents a patient with acute on chronic anemia that had previously undergone a thorough investigation with few answers. Serial Hgb monitoring and follow-up endoscopy led to the discovery and treatment of his duodenal DL.