A Challenging Case of Jejunal Dieulafoy’s Lesion: A Rare Cause of Refractory Lower-Gastrointestinal Bleeding

Patient: Male, 41-year-old Final Diagnosis: Jejunal Dieulafoy’s lesion Symptoms: Hematochezia • loss of consciousness • melena • vomiting Medication: — Clinical Procedure: Exploratory laparotomy w/partial jejunal resection • lower GI endoscopy • push enteroscopy w/hemoclip application • upper GI endoscopy Specialty: Gastroenterology and Hepatology • Histology and Embryology • Surgery OBJECTIVE: Rare disease BACKGROUND: Dieulafoy’s lesion is a rare cause of severe gastrointestinal (GI) bleeding, accounting for approximately 1-2% of all cases of GI hemorrhage. Nevertheless, it can be life-threatening without prompt intervention. Dieulafoy’s lesion of jejunal origin can be particularly challenging to identify due to the inability of conventional endoscopic techniques to visualize the jejunum. This case report emphasizes the difficulties in diagnosing and managing jejunal Dieulafoy’s lesions and highlights the methods by which to approach refractory bleeding. CASE REPORT: This is a case of a 41-year-old man with a history of uncontrolled hypertension who presented with an episode of syncope and melena associated with low hemoglobin levels requiring multiple packed red blood cell transfusions. This warranted searching for a source of bleeding within the gastrointestinal tract via 2 upper-GI endoscopies, a colonoscopy, and an abdominal computed tomography angiogram, all of which failed to localize the site of bleeding. A push enteroscopy was required to identify the lesion in the jejunum, but the bleeding was not controlled despite the application of hemoclips and epinephrine. Consequently, laparotomy and re-section of the jejunal segment containing the Dieulafoy’s lesion was performed and the diagnosis was established histopathologically. The patient recovered well and was discharged 4 days after the procedure. CONCLUSIONS: Suspicion of a jejunal Dieulafoy’s lesion should be raised if both upper- and lower-GI endoscopies yield unre-markable findings. Ideally, a push enteroscopy should be utilized diagnostically and to conservatively manage the bleeding. However, laparotomy should be considered in refractory lesions or in the presence of hemodynamic instability.