A Jejunal Dieulafoy Lesion in a Woman with AML-A Case Report

Abstract

Purpose: Dieulafoy lesions are responsible for 2 percent of upper gastrointestinal bleeding. The incidence of these lesions in lower gastrointestinal bleeding is unknown, though it is felt to be much lower than the aforementioned value; these lesions are usually apparent only after multiple endoscopic surveys. This case addresses this infrequently encountered disease entity and also posits endoclip placement as a non-surgical alternative for these lesions when they develop in the jejunum. Course: A 76-year-old woman with a past medical history of atrial fibrillation and acute myeloid leukemia with failed remission was admitted for initiation of another course of chemotherapy with Cytarabine and Clofarabine. Her admission labs were significant for a hemoglobin of 8.3 mg/dL and a platelet count of 63 K/μL. On the second hospital day, the patient developed melena. Despite multiple blood transfusions, the patient's hemoglobin remained unstable - the patient was moved to the ICU, and the Gastroentology Service was notified. An EGD was done which revealed antral gastritis; no source of bleeding was identified. Colonoscopy additionally revealed no source of bleeding. The patient was placed on IV acid suppression. Serial CBCs were monitored. Chemotherapy-induced enteritis was posed as a cause of her bleeding, and transfusions were continued. Complicating matters was the inability to perform platelet apheresis, owing to the development of multiple platelet antibodies by the patient. IVIG was given in an attempt to bolster the patient's platelet count, but this was unsuccessful. A tagged red blood cell scan was performed, and this demonstrated bleeding in the proximal jejunum. Embolization in this area was attempted, but the culprit vessel could not be identified. A push enteroscopy was performed, and this showed a Dieulafoy lesion in the proximal jejunum. Epinephrine was injected into the lesion and an endoclip was placed. CBCs were monitored for another 24 hours - as there was a continued decrease in the patient's hemoglobin, a repeat enteroscopy was done and another endoclip was placed with adequate hemostasis as evidenced by a stable hemoglobin trend for the duration of the patient's hospital course. Discussion: In a patient with an inconclusive source of gastrointestinal bleeding despite thorough endoscopic surveys, small bowel pathologies such as Dieulafoy lesions (in this case jejunal Dieulafoy lesions) should be considered. Additionally, endoclip placement may represent a new treatment paradigm for these lesions, thus not subjecting the patient to long-term complications of segmental resections, such as adhesion development and possible small bowel obstruction.