This Aimless Cobra Spits Blood: A Dieulafoyʼs Lesion as the Cause of Massive Hematemesis

Abstract

Introduction: Dieulafoy's lesion is a tortuous, dilated aberrant submucosal artery that can erode through the mucosa and rupture spontaneously to cause severe gastrointestional bleeding. The lesion is most commonly found in the proximal stomach along the lesser curvature within 6 cm of gastroesophageal junction. It has up to 80% mortality rate because of its tendency to cause intermittent but severe bleeding and diagnostic challenges.Table 1: Neuroendocrine Tumor Characteristics on Surgical PathologyFigure 1Figure 2Case: A 39-year-old Hispanic male presented with sudden onset of melena and painless massive hematemesis. He was a nonsmoker and nonalcoholic with no history of NSAID use. His past medical history was significant for GERD and similar complaints of melena and hematemesis 8 years previously. Extensive prior investigations including CT abdomen and pelvis, esophagogastroduodenoscopy (EGD) and nuclear medicine scan failed to reveal the source of bleeding. He was hemodynamically stable at the time of presentation but his hemoglobin dropped from a baseline of 13 to 8. EGD showed mild reflux esophagitis, acute duodenitis, and gastric varices in the fundus of the stomach. CTA showed a small tangle of abnormally enlarged tortuous bleeding vessels along the posterior cardia of stomach with the absence of early venous return, suggestive of multiple Dieulafoy's lesions. IR-guided mesenteric angiogram was subsequently performed with successful embolization of multiple Dieulafoy's lesions arising from the proximal splenic artery and coursing through the region of the gastric cardia and fundus. The patient had an uneventful recovery and he was discharged home. He did not have recurrence of bleeding and his hemoglobin was within the normal limits at a 3 month follow-up visit.Figure 3Discussion: Diagnosis of Dieulafoy's lesion presents a formidable challenge for physicians and radiologists. Endoscopy is the diagnostic modality of choice but it is often unrevealing due to small size of the Dieulafoy's lesion, normal appearance of surrounding mucosa and intermittent bleeding patterns. These lesions have been known to be mistaken for other entities such as arteriovenous malformations, aneurysms, Mallory-Weiss tears and gastric varices, such as in our case. Contrast-enhanced CT and angiography can be helpful in cases where initial endoscopy fails to reveal the diagnosis of Dieulafoy's lesion and can offer minimally invasive therapeutic alternatives to surgical resection through selective arterial embolization.