Dieulafoyʼs Lesion of Esophagus Managed with Injection Therapy

Abstract

Purpose: We report the case of a 25-year-old male from Gambia, West Africa who presented complaining of vomiting bright red blood for 3 days. He had been seen in emergency department of a different hospital 3 days prior and sent home, as the vomiting had resolved. He subsequently had 1 episode hematemesis so he came to our ED for further evaluation. He reported passing black stool on one occasion. He denied abdominal pain, fever, dizziness, and shortness of breath. He denied smoking, alcohol use, or use of any drugs, except that he had taken a total of 4 Advil tablets prior to seeing melena. On examination, he was afebrile, slightly tachycardic with a pulse of108; BP was 142/85 with no orthostasis. The abdominal exam revealed a soft, non-tender abdomen with normoactive bowel sounds. Stool guiac was positive. Laboratory values were as follows: hemaglobin and hematocrit (H&H) 5.7 g/dl/16.3%; INR 1.3; BMP values were within normal limits. Chest x-ray and plain abdominal film revealed no significant findings. EKG demonstrated sinus tachycardia at 105 bpm, but was otherwise unremarkable. GI consultation was requested, and 4 units of PRBC transfusion were recommended to keep hemoglobin above 9. Subsequently, the patient was taken for upper endoscopy. Upper endoscopy revealed an actively bleeding Dieulafoy's lesion in the mid esophagus, along with a hiatal hernia, which was controlled with sclerotherapy using epinephrine and cautery with BICAP. The patient was monitored in the ICU, the blood counts stabilized, and there were no further episodes of hematemesis or melena. The patient was subsequently discharged home on a proton pump inhibitor. Discharge H&H were 7.6 g/dl and 21%. Three days later, he returned to the ED complaining of constipation. On this admission, guiac was positive and the H&H were was 7.1 g/d and 21.0%. GI consultation was again requested, and the patient was taken for repeat upper endoscopy which demonstrated both cauterized lesions in the esophagus to be well-healed with a clean, white base and no evidence of recurrent bleeding. The H&H remained stable, and the patient was discharged home on iron tablets and followed in the GI clinic with no episodes of recurrent bleeding.[figure1]Figure