A bleeding duodenal lesion

A 40-year-old man with no known underlying diseases developed epigastric pain and passed tarry stools for 2 weeks. There was no noted coffee-ground vomitus. Upon arriving at the hospital, he had a hemoglobin level of 9 mg/dL. Esophagogastroduodenoscopy revealed oozing of the duodenal mucosa (Figure 1) The patient underwent blood transfusion with six units of packed red blood cells. Another episode of severe diarrhea with tarry stools and hemodynamic instability occurred after admission. However, no definite extravasation was detected on computed tomography angiography. On repeated esophagogastroduodenoscopy, the previously identified duodenal lesion kept oozing.

The oozing duodenal mucosa on the opposite side of superior duodenal angle, detected on repeated esophagogastroduodenoscopy, was classified as a Dieulafoy's lesion. Dieulafoy's lesion is a small mucosal erosion into a caliber-persistent and abnormally large submucosal artery. The lesion most commonly affects elderly men, and is typically located in the proximal stomach.¹

For the uncommon bleeder with no easily defined feeding vessels, endoscopic band ligation (EBL) was performed using the Multiple Band Ligator (Boston Scientific, The Speedband Superview Super 7, Boston, USA) (Figure 2A) to suction the bleeding target lesion into the cap, occupying the endoscopic view. The rubber band was placed around the bleeding site (Figure 2B). Twenty-seven days after the patient's discharge, repeat esophagogastroduodenoscopy showed a healing scar (Figure 2C).

Dieulafoy's lesions cause 2% of gastrointestinal hemorrhages, and only 15% of cases involved the duodenum.¹ For Dieulafoy's lesions, there is no definite consensus on the treatment and the options are dependent on the site of the lesion and available expertise. Several endoscopic techniques have been developed. Some studies have suggested that endoscopic mechanical hemostatic methods were more effective in achieving hemostasis than injection or thermal treatment.² EBL for Dieulafoy's lesions has gained increasing acceptance than hemoclipping because of favorable clinical outcome.^{3, 4} Hemoclipping is sometimes not easy to apply in duodenum when the angle of approach is tangential or when the location has no space to deploy the clip. Delayed bleeding of a residual vessel within a necrotic ulcer is problematic. In one study, about 3% of patients experienced delayed bleeding at the previous EBL site after EBL treatment.⁵

The authors declare no conflict of interest.

The study participant provided informed consent, and the study design was approved by the appropriate ethics review board.