A Rare Dieulafoy Lesion in the Periampullary Duodenum

Abstract

The calamity of diagnosing a Dieulafoy lesion increases exponentially when it presents atypically. Our case of a periampullary Dieulafoy lesion presents as a diagnostic challenge as it diverges from the usual epidemiological and diagnostic criteria established for these rare defects that account for less than 2% of obscure gastrointestinal bleeding. 87-year-old female patient with a history of GERD, gastritis, diverticulosis and chronic NSAID use presented with melena, diffuse abdominal pain and NBNB emesis. In the setting of her acute anemia with a Hb of 5.9 and tachycardia, an EGD demonstrated a single medium-sized Dieulafoy lesion in the second portion of the duodenum next to the major papilla oozing blood that was controlled with a bipolar diathermy. Daily PPIs, discontinuation of NSAIDs, and appropriate outpatient follow-up were recommended. Dieulafoy lesions are dilated submucosal veins that are exposed to the surface and endoscopically visualized as bleeding points without surrounding erosions or ulcerations. Typically, they present in elderly males with a history of NSAID or blood thinner usage, with 75% of them occurring in the stomach, usually within 6 cm of the gastroesophageal junction. Diagnosis in anatomically inaccessible locations, such as the periampullary portion of the duodenum like our patient, often requires push enteroscopy, side visual scope, angiography, technetium-99m labelled bleeding scan, and in some cases, multiple endoscopies to detect this fatal defect. Primary hemostasis can be achieved with electrocoagulation, which was the treatment of choice with our patient, or with sclerotherapy, thermocoagulation, argon plasma coagulation or clips with equal results. With the recurrence rate ranging from 9% to 40%, secondary hemostasis can be accomplished through repeat endoscopy, angiography, or rarely, surgical wedge resection. With proper diagnosis and treatment, the rate of mortality has decreased from 30% from the 1970s to currently 8%, however the difficulty lies in vigilant detection, especially in anomalous locations, as was the case in our patient. Watch the video: https://goo.gl/DihM7M1691_A Figure 1. Bleeding periampullary Dieulafoy lesion1691_B Figure 2. Primary hemostasis of Dieulafoy lesion through electrocoagulation