A Rare Case of Jejunal Dieulafoyʼs Lesion in a 21-Year-Old Male

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Purpose: Dieulafoy's lesion is a rare and potentially life threatening cause of gastrointestinal bleeding occurring in only 2% of all gastrointestinal bleeds in adults. The most common site is the proximal third of the stomach within 6cm of the gastro-esophageal junction. Other sites include the duodenum, colon, jejunum and esophagus, with the duodenum being the most common extra-gastric site. Mortality rates for these lesions approached 80% prior to the era of endoscopy, however, rates have decreased significantly to less than 10% with use of newly available treatment options. A 21-year-old male presented with complaint of blood in his stools. He had no significant past medical history. Two days prior, he had eaten at a Chinese restaurant. Later, he had 3 heavy bowel movements and noticed fresh blood mixed with his stool. He denied any medication use, smoking or any other substance abuse. His father was diagnosed at 58 years of age with colon cancer. Physical exam revealed a hemodynamically stable, obese male. A rectal exam revealed gross blood. His hemoglobin level was 11.4. An initial CT scan of abdomen was negative for any significant findings. The patient had 3 bloody bowel movements over the next 12 hours and became hemodynamically unstable. He was aggressively resuscitated with fluids and transfused with packed red blood cells. An emergency endoscopy and sigmoidoscopy did not reveal any source of bleeding. A mesenteric angiogram was performed revealing a site of extravasation in left mid-abdomen from a jejunal branch. Embolization was performed. Additional foci of extravasation were located in jejunal branches of superior mesenteric artery where embolization could not be performed due to inaccessibility. Following angiogram, he underwent exploratory laparotomy in which 22cm of jejunum was resected and ‘jejunal polyp' was found. The ‘jejunal polyp' was found to be a dieulafoy's lesion on pathologic examination. The current report of jejunal dieulafoy's lesion is one of less than two dozen appearing in the literature. Before considering this rare diagnosis, upper and lower GI bleeds must be ruled out. Periodic or serial endoscopy and colonoscopy may be needed due to intermittent nature of bleeding. Following this, a tagged red blood cell scan as well as an angiogram may be performed in case of an active bleed. Dieulafoy's lesion must be considered as a part of differential diagnosis and must be acted upon promptly given its life threatening nature. However, this should only be done after an upper or lower GI source is excluded.