The Story of a Duodenal Bulb Dieulafoyʼs Lesion that Bled Massively and then Bled Again Three Years Later!

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Purpose: Dieulafoy's lesions are an uncommon but important cause of recurrent UGIB. Dieulafoy's lesions of the duodenal bulb are extremely rare. We report a case of a Dieulafoy's lesion of the duodenum that bled and bled again three years later. Case Report: 47-year-old female presented to our emergency room with multiple episodes of coffee-ground emesis and melena. She denied abdominal pain, ASA, NSAID or anticoagulant use. Patient was orthostatic with a 3 gm/dl drop in hemoglobin. Nasogastric lavage revealed coffee grounds and rectal exam showed melena. Patient was admitted three years prior with a 6 unit PRBC bleed that was erroneously attributed to duodenitis. Review of those endoscopic photographs revealed a Dieulafoy's lesion of the duodenal bulb. After stabilizing the patient, EGD was performed which revealed a protruding 3 mm vessel in the duodenal bulb without local ulceration. The diagnosis of a bleeding Dieulafoy's lesion was made and two hemoclips were deployed to achieve hemostasis. Post-procedure there was no further bleeding. A follow-up EGD the following week revealed clips in place and resolution of the visible vessel. Another follow-up EGD in seven weeks showed normal duodenal bulb, loss of prior clips and disappearance of the Dieulafoy's lesion. Discussion: A Dieulafoy's lesion is a dilated aberrant sub-mucosal vessel about 1-3 mm in diameter or ten times the size of normal sub-mucosal capillaries. This large vessel can erode through the overlying epithelium in the absence of a primary ulcer. Dieulafoy's lesions account for less than 1 percent of cases of severe UGI hemorrhage and endoscopy is the diagnostic modality of choice. The finding of a protruding vessel, with or without active bleeding, that is not associated with an ulcer should suggest the possibility of a Dieulafoy's lesion. Dieulafoy's lesions are small and can be easily missed or they can disappear retracting back into the mucosa. In this case, we have photographs documenting a duodenal Dieulafoy that bled, resolved without therapeutics, and then bled again three years later. This indicates that a Dieulafoy is a ticking time bomb that can cause recurrent bleeding. Endoscopic management has success rates reported to be as high as 95 %. Therapeutic modalities including epinephrine injection, electrocautery, hemoclip application, rubber band ligation and argon plasma coagulation have been used. Recent data shows that therapy with hemoclip results in greater initial hemostatic efficacy and reduced recurrent bleeding as compared with injection therapy.