P2104 - Severe Gastrointestinal Bleed Due to Dieulafoy Lesion Treated with Endoscopic Ultrasound Guided Intervention

Shivangi Gohil, MD¹, Shruti Verma, MD², Rishi Grewal, MD^1
1Overland Park Regional Medical Center, Overland Park, KS; ²HCA, Overland Park, KS

Introduction: A dieulafoy lesion (DL) represents a rare and underdiagnosed cause of obscure upper gastrointestinal(GI) bleeding caused by a submucosal vascular malformation of the GI tract present predominantly in the lesser curvature of the stomach. It represents a diagnostic challenge on initial endoscopic evaluation due to the intermittent nature of bleeding and anatomically inaccessible , small or subtle lesions.

Case Description/Methods: A 33-year-old man presented with epigastric abdominal pain and black tarry stools for two days. He was diagnosed with acute appendicitis and managed with laparoscopic appendectomy. Of note, he had got splenic artery embolization secondary to partial splenic rupture in the past. Three days later, he had a large volume bloody hematemesis leading to a syncopal episode due to hemorrhagic shock and disseminated intravascular coagulation. He was then started on octreotide, pantoprazole, vasopressor infusions and massive transfusion protocol was followed. An urgent upper GI endoscopy (UGIE) revealed fundal bleeding which did not resolve despite local epinephrine injections, and thus coiling of the distal left gastric branch and subsequent proximal left gastric embolization was performed. However, due to persistent anemia despite multiple repeat endoscopies, exploratory laparotomy with gastrotomy was done and two liters of blood was evacuated. Despite the gastrotomy, recurrent GI bleeding persisted requiring transfusions of total 50 units packed red blood cells, 9 units of platelets, 20 units of plasma and 6 units of cryoprecipitate. Finally, endoscopy with endoscopic ultrasound (EUS) guidance revealed clotted blood in the gastric fundus and a DL was identified in the gastric cardia. EUS guided angiotherapy and hemostatic clipping helped in achieving hemostasis. After a prolonged hospitalization, patient was discharged with plans for a future splenectomy.

Discussion: UGIE was previously considered the gold standard for diagnosing DL; however, EUS has been gaining more popularity for the management of DL due to its higher success rates. In addition to UGIE, EUS can help in identifying a non-actively bleeding DL, performing EUS-guided therapy and for monitoring effectiveness of therapy without requiring any surgical intervention in upto 90% of cases. It may be performed after inconclusive UGIE and even the non active bleeding lesions can be marked with metallic clips for treating DL. However, in refractory cases, transcatheter arterial embolization or surgery may be required.


Disclosures:


Shivangi Gohil, MD¹, Shruti Verma, MD², Rishi Grewal, MD¹. P2104 - Severe Gastrointestinal Bleed Due to Dieulafoy Lesion Treated with Endoscopic Ultrasound Guided Intervention, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.