3145 Dieulafoy's Lesion: An Underdiagnosed and Underrecognized Cause of Gastrointestinal Bleed

Abstract

INTRODUCTION: Acute gastrointestinal bleed accounts for nearly 50-150 cases per 100,000 each year. The etiology in the majority of cases is peptic ulcer disease (PUD). Dieulafoy's lesion is a rare (accounts for 1-2%), but potentially life-threatening cause of gastrointestinal (GI) bleed. We present a case of recurrent hemodynamically significant upper GI bleeding requiring multiple hospitalizations and endoscopies to identify a duodenal Dieulafoy's lesion as the primary source for bleed. CASE DESCRIPTION/METHODS: A 52-year-old male with a history of chronic alcohol use was admitted to the intensive care unit for the third time within a one-year duration for recurrent episodes of melena. During the first two episodes, upper GI endoscopy was positive for mild gastropathy, and a small 4-5 mm partially healed duodenal ulcer respectively. The exam was negative for any esophageal varices or other upper GI pathologies. The patient responded well both times to medical therapy and subsequently discharged home. In the third admission for similar presentation with melena and hemodynamically significant GI bleed, endoscopy was positive for an actively bleeding duodenal Dieulafoy's lesion. Bleeding was controlled with hemostatic clips and epinephrine injections. He was discharged home 48 hours after stabilization. Post-discharge, he was followed for a year, and he remained asymptomatic. It was therefore concluded that Dieulafoy's lesion was the likely cause of GI bleed that had evaded diagnosis during the first two endoscopies. DISCUSSION: Dieulafoy's lesion is a dilated submucosal vessel that erodes the epithelium and most commonly found in the stomach. Approximately one-third of the lesions are extragastric and located in the duodenum and colon. They are typically seen in men, around the fifth decade, in the presence of comorbidities such as hypertension, diabetes, chronic kidney disease, or alcohol abuse. Dieulafoy's lesions are under-diagnosed as they are silent until presentation. Approximately 33% of the lesions may require more than one EGD to identify the active source of bleeding, especially in the presence of other causes of GI bleed such as PUD. In our patient, the culprit for his recurrent GI bleeding was identified as Dieulafoy's lesion on the third endoscopy. We want to highlight the importance of the diagnosis and management of Dieulafoy's lesion as it can significantly decrease the mortality from 80% to 8.6%.