S3458 A Tale of Two Dieulafoy’s: Massive GI Hemorrhage from Synchronous Dieulafoy Lesions

Abstract

INTRODUCTION: Dieulafoy lesions (DL) are an elusive source of gastrointestinal hemorrhage accounting for 5% of all cases. They consist of large aberrant submucosal arterioles that erode through overlying epithelium. Patients present with hematemesis, melenic stools, and/or hemodynamic instability. Bleeding is from a single lesion in the stomach (64%), small intestine (20%), colon (10%), or esophagus (2%). Diagnosis is difficult in the absence of overt bleeding and repeat endoscopy is often required. Management includes epinephrine injection, thermal ablation, hemoclips, or resection. Unfortunately, recurrence can be seen in 5-10% of cases. We report an exceedingly rare case of two synchronous DL actively bleeding during one hospitalization. CASE DESCRIPTION/METHODS: A 61 year old male with ESRD, CAD status-post bypass grafting, atrial fibrillation, and heart failure status-post mitral valve replacement presented with four weeks of melena. Index endoscopy demonstrated duodenal bulb and cecal angioectasias that were ablated with snare polypectomy of four polyps. Bleeding persisted so capsule endoscopy was pursued showing fresh blood in the jejunum and distal ileum. Upper double balloon-assisted enterography (DBE) showed an actively bleeding DL in the mid-distal jejunum that was treated with APC, hemoclips and marked with India Ink. Melena and transfusion-dependent anemia persisted and repeat upper DBE showed oozing from prior DL ablation, thus retreated with APC. Bleeding continued but IR angiogram was unrevealing, so resection was pursued. Unfortunately, despite resection, video capsule, and two colonoscopies with hemoclip placement at polypectomy sites, bleeding continued. A lower DBE revealed an actively bleeding DL 50cm proximal to the ileocecal valve that was treated with APC and hemoclips. Hemostasis was achieved and the patient was discharged. DISCUSSION: Despite endoscopy and small bowel series, the source is not found in up to 5% of overt GI hemorrhages. While DL account for only 5% of GI bleeding cases, they are important due to their propensity to cause significant hemorrhage. DL are typically solitary; only two cases of synchronous DL have been reported in literature, and were isolated to the stomach or stomach and small bowel. This is an unusual case of persistent GI bleeding caused by two active small bowel DL (distal jejunum and ileum) which were synchronously bleeding during one hospital admission. As far as we know, this is the only reported case of two actively bleeding DL in the small bowel.Figure 1.: Initially identified DL in mid-distal jejunum treated with APC & hemoclips.Figure 2.: Synchronous DL 50cm from ICV.