Diagnosis of massive obscure gastrointestinal bleeding from a Dieulafoy lesion identified by intraoperative enteroscopy

A 32-year-old woman was admitted to the emergency department with syncope, shock, and persistent hematochezia. Her hemoglobin had drastically declined from 14.1 g/dL to 5.5 g/dL within 4 hours. Prompt, although challenging, central venous catheterization coupled with rapid intravenous fluid resuscitation elevated her systolic blood pressure from 60 mmHg to approximately 90 mmHg. Computed tomographic angiography (CTA) revealed a dense shadow in the bowel lumen in the left upper abdomen ([Fig. 1]). Consequently, a multidisciplinary team collaborated to perform an open laparotomy, complemented by intraoperative endoscopy.

Fig. 1 Computed tomographic angiography revealed a dense shadow (arrows) in the bowel lumen in the left upper abdomen.

During the intraoperative endoscopy, a hemispherical mucosal protrusion, approximately 0.8 cm in size, was identified in the upper jejunum ([Video 1]). The mucosa’s surface was smooth, and a jet-like hemorrhage emanated from its apex. Endoscopic titanium clip occlusion was performed to stop the bleeding, followed by surgical resection of this intestinal segment ([Fig. 2]).

Intraoperative enteroscopic identification of the source of massive obscure gastrointestinal bleeding.Video 1

Fig. 2 Intraoperative endoscopy showed a distinct hemispherical mucosal protrusion in the upper jejunum. The mucosa’s surface was smooth, and a jet-like hemorrhage emanated from its apex. Endoscopic titanium clip occlusion was performed to stop the bleeding.

Subsequent histological examination revealed a focal thick-walled, lumen-dilated artery with localized hemorrhage within the submucosal layer of the small intestine, exhibiting morphological features consistent with constant-diameter arteriopathy, known as Dieulafoy disease ([Fig. 3]).

Fig. 3 Histological examination revealed a Dieulafoy lesion.

Intraoperative endoscopy, angiography, and indeed device-assisted enteroscopy remain the recommended first-line modality for treating hemodynamically unstable patients with catastrophic obscure gastrointestinal bleeding, despite the rapid technological advances in capsule endoscopy and emergency enteroscopy [1] [2]. Intraoperative endoscopy is more accurate and effective for small-bowel bleeding than interventional angiography, as the latter can be challenging where there is a slow bleeding rate, difficult vascular access, or extensive collateral circulation, and it also carries a relatively high complication rate [3]. For patients with brisk bleeding, CTA is favored as a noninvasive tool to identify the potential source and determine the optimal timing for intervention, thereby facilitating a prompt and precise intraoperative endoscopy plan [4]. Furthermore, this case exhibited a rare clinical feature of a Dieulafoy lesion which, unlike most reported Dieulafoy lesions, mimicked a stromal tumor during the acute hemorrhagic phase [5].

Endoscopy_UCTN_Code_CCL_1AC_2AB

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Liu K, Kaffes AJ. Review article: the diagnosis and investigation of obscure gastrointestinal bleeding. Aliment Pharmacol Ther 2011; 34: 416-423
• 2 Gerson LB, Fidler JL, Cave DR. et al. ACG clinical guideline: diagnosis and management of small bowel bleeding. Am J Gastroenterol 2015; 1265-1287
• 3 Pasha SF, Leighton JA. Detection of suspected small bowel bleeding: challenges and controversies. Expert Rev Gastroenterol Hepatol 2016; 10: 1235-1244
• 4 Fidler JL, Goenka AH, Fleming CJ. et al. Small bowel imaging: computed tomography enterography, magnetic resonance enterography, angiography, and nuclear medicine. Gastrointest Endosc Clin N Am 2017; 27: 133-152
• 5 Romãozinho JM, Pontes JM, Lérias C. et al. Dieulafoy’s lesion: management and long-term outcome. Endoscopy 2004; 36: 416-420

Publikationsverlauf

Artikel online veröffentlicht:
25. März 2025