A Jejunal Dieulafoy Lesion: Rare Case Necessitating Surgical Intervention. (2020)

• Record Type: Journal Article
• Authors: Yehya, Misbah; Mayovska, Oksana; Flick, Amanda; Moszczynski, Zbigniew
• Is Part Of: International journal of surgery case reports. Volume 72(2020)
• Page Start: 541
• Page End: 545
• Publication Date: 2020
• Subjects: Dieulafoy lesion -- Gastrointestinal bleeding -- Hemorrhagic shock -- Hematochezia -- Jejunum; Surgery -- Periodicals; Surgical Procedures, Operative -- Periodicals; Surgery; Electronic journals; Periodicals; 617.005
• DOI: 10.1016/j.ijscr.2020.06.098
• Languages: English
• ISSNs: 2210-2612

Abstract

Highlights: Dieulafoy lesions are aberrant submucosal lesions that, in rare circumstances, can result in massive gastrointestinal bleeding. These lesions are particularly rare in the jejunum, thus usual diagnostic and therapeutic modalities such as endoscopy may prove difficult. Additional imaging such as angiography or radionuclide scanning can be beneficial in identifying the source of bleeding. If advanced endoscopic instruments are unavailable at one's facility, the surgeon must consider operative intervention for life-saving measures. The operative findings and management discussed can guide clinicians unexposed to this disease process when surgical intervention is imminent. Abstract: Introduction: Dieulafoy lesions are enlarged atypical submucosal vessels that erode the superimposing epithelium in the absence of a primary ulcer. They occur predominantly in the gastric mucosa; however, cases have been seen throughout the gastrointestinal (GI) tract, and rarely, the jejunum. These lesions can cause massive GI hemorrhage leading to shock. Case Presentation: We present a healthy 19-year-old male who arrived at our institution's emergency department with multiple episodes of hematemesis and hematochezia that began earlier that morning. The patient was resuscitated and underwent a computerized tomographic (CT) angiography that did not identify any areas of active extravasation. The patient was then taken for an emergent upper and lower endoscopy that was inconclusive. He was subsequently sent for a tagged red blood cell scan, which demonstrated active bleeding in the proximal jejunum. Shortly thereafter, the patient began to decompensate requiring additional blood products and vasopressors. The decision was made for immediate operative intervention, which identified the bleeding Dieulafoy lesion (confirmed by histopathology) in the jejunum. Discussion: Dieulafoy lesions are rare with an initial presentation of upper or lower GI bleeding, generally treated with endoscopic intervention. They are predominately found in the stomach or duodenum. When no clear source is identified by endoscopy, further diagnostic testing may be of value. Various imaging modalities exist; however, CT angiography or radionuclide scanning are particularly sensitive and can be beneficial in localizing the bleed when preparing for operative intervention. Conclusion: With advances in endoscopic techniques, surgical intervention is rarely performed for a Dieulafoy lesion. If endoscopy is unsuccessful, additional imaging can be obtained to localize the source of bleeding. However, in emergent cases, when additional imaging cannot be obtained due to lack of time or resources, adequate resection of the lesion should be performed for complete resolution of the disease process. Based on the case presentation and pathologic findings, this case provides further insight into Dieulafoy lesions and the rare need for surgical management.