Dieulafoy's lesion (DL) is an uncommon cause of life-threatening gastrointestinal (GI) bleeding. It can occur in any part of the GI tract, including the stomach, duodenum, colon, and esophagus.(1) The exact cause of DL is yet to be determined. Clinical presentation includes painless upper GI bleeding, including melena, hematochezia, and hematemesis, or rarely iron deficiency anemia (IDA); however, most of the patients are asymptomatic.(2)

A 80-year-old man was admitted to the medicine department with complaints of 2 episodes of dark coloured vomitus as well as melena.] On initial physical examination, the patient was in fair general condition, with the presence of pallor, heart rate (HR): 119 bpm, respiratory rate (RR): 19 rpm, SaO2: 95%, bloodpressure (BP)of 100/70 mmhg, soft abdomen, not painful on palpation Admission hemoglobin 8.1 g/dl, follow-up blood count 24 hours after transfusion of erythrocyte concentrates hemoglobin (Hb) 9.2 g/dl. Once the hemoglobin was elevated, upper gastrointestinal endoscopy was performed, and the following findings were reported: Normal mucosa in first part of duodenum. A fresh clot with ooze noted in distal second part of duodenum, suggestive of Dieulafouys lesion Treatment Endotherapy done with Adrenaline injection(1:10000), three aliquots of 3cc each injected around the lesion to achieve adequate mucosal blanching and hemostasis. Repeat endoscopy was done after 48 hours, which showed complete resolution of the lesion which was seen in initial endoscopy, with no active bleeding. Patient with satisfactory evolution was discharged with an appointment after outpatient consultation. Figure 1 Figure 2

Upper gastrointestinal bleeding is a common health problem, with patients typically presenting with symptoms such as hematemesis, coffee-ground emesis, or melena. It is estimated that the annual incidence is approximately 80 to 150 per 100,000 population.(3) Dieulafoy’s lesion is a persistent calibre artery anomaly that is relatively rare yet possibly fatal because of gastrointestinal bleeding. Advances in endoscopic technique have greatly assisted in early diagnosis and added various options for the treatment for this lesion, aetiology is still uncertain. They are twice as common in males as females, more commonly seen in the elderly population. Associated comorbidities are present in more than 50% of patients, most frequently cardiac and renal diseases.(4) They are characterized by the presence of an abnormally large-caliber submucosal artery, typically measuring 1– 3 mm in diameter, that fails to taper as it approaches the mucosal surface. The overlying mucosa becomes thinned and eventually erodes due to mechanical pressure, ischemia, or minor trauma, resulting in a small mucosal defect—usually less than 3 mm—through which the artery ruptures, causing sudden and often massive arterial bleeding. The surrounding mucosa appears normal, and histologically, the artery itself is structurally normal, distinguishing this lesion from other vascular malformations such as angiodysplasia or aneurysms. Gallard in 1884 described Dieulafoy's lesions (DLs) as a ‘miliary aneurysm’.(5) Later in 1898, Paul Georges Dieulafoy, a Professor of Pathology in Paris, France was the first to describe a series of patients who presented with massive haematemesis due to a bleeding gastric vessel without any evidence of ulceration at autopsy, referred to these lesions as exulceratio simplex and felt that these were the result of injury to the gastric mucosa with subsequent haemorrhage from a normal submucosal artery.(6) A large majority of patients presenting with Dieulafoy’s lesions present with a sudden-onset, massive, recurrent bout of painless hematemesis; however, melena and hematochezia may also be present(7), approximately half of patients with diagnosed Dieulafoy's lesions have been noted to be due to NSAIDs, warfarin, and aspirin use.(8) The lesion was predominantly found in the proximal stomach. Repeat endoscopies were needed in 33% of the patients in order to make the correct diagnosis. When preoperative diagnosis and localization were made, surgery was an effective therapeutic modality. Therapeutic endoscopy was successful in achieving permanent hemostasis in 85% of the reported cases.(9) The diagnosis of Dieulafoy’s lesion relies primarily on endoscopy, which serves both diagnostic and therapeutic purposes. The characteristic endoscopic appearance includes active spurting or oozing of blood from a pinpoint mucosal defect in otherwise normal mucosa, a visible protruding vessel without ulceration, or an adherent clot attached to normal mucosa with a small base. Injection therapy with diluted epinephrine (1:10,000) provides temporary control through vasoconstriction and tamponade. However, definitive hemostasis is best achieved by mechanical or thermal methods. Mechanical modalities such as hemoclips or endoscopic band ligation directly close the bleeding vessel and have the lowest rates of rebleeding. Combination therapy, most commonly epinephrine injection followed by mechanical clipping has been shown to reduce rebleeding compared to single-modality treatment. In patients who do not respond to endoscopic management, transcatheter arterial embolization provides an effective and minimally invasive alternative, selectively occluding the bleeding vessel while preserving adjacent tissue perfusion. Surgical intervention, such as local wedge resection or oversewing of the bleeding point, is now reserved for the small subset of patients with refractory bleeding despite endoscopic and radiologic therapy. Post-procedure management includes intravenous proton pump inhibitors, close hemodynamic monitoring, and repeat endoscopy if rebleeding is suspected.

Dieulafoy’s lesion is a rare but important cause of acute gastrointestinal bleeding that can often be overlooked because the surrounding mucosa appears normal. Early recognition through careful endoscopic evaluation is critical for timely diagnosis and effective management. Long-term follow-up is essential to monitor for rebleeding and to manage any underlying comorbidities that may predispose to recurrence. Early multidisciplinary collaboration between gastroenterologists, radiologists, and surgeons ensures optimal outcomes in such complex presentations.

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