A 69-year-old patient with massive hematemesis was transferred to our intensive care
unit. Additional clinical symptoms were melena, fatigue, and severe anemia with an
initial hemoglobin level of 6.9 g/dL. The patient’s medical history was uneventful
and without significant comorbidity. Previous endoscopic examinations performed elsewhere
had revealed an angiodysplastic lesion in the gastric fundus, as well as two non-bleeding
angiodysplastic lesions in the cecum, which had been treated with argon plasma coagulation
(APC) and hemoclip application. Unfortunately, the patient’s physical condition progressively
worsened, with severe gastrointestinal (GI) bleeding, tachycardia, and hypotension
despite endoscopic intervention and the transfusion of numerous units of red blood
cells (n = 12) and fresh frozen plasma (FFP) over the next 72 hours. The clinical
course was additionally complicated by aspiration-induced pneumonia and antibiotic
treatment was required (ceftriaxone 2 g once daily and metronidazole 500 mg three
times per day).
Because further episodes of significant hematemesis occurred repeatedly and gastroscopy
failed to identify the bleeding source, we decided to intensify the diagnostic approach
and performed an upper GI single-balloon enteroscopy (SIF-Q180; Olympus), which identified
a Dieulafoy-like pulsating lesion in the distal jejunum ([Fig. 1]). The lesion was marked with two hemoclips and definitive hemostasis was achieved
following application of an over-the-scope clip (OTSC; Ovesco, Tübingen, Germany).
For this purpose, the 14/6 t OTSC clip was mounted on a colonoscope (CF-H165L; Olympus)
and successfully released at the marked site of bleeding in the distal jejunum ([Video 1]).
Fig. 1 Image during single-balloon enteroscopy showing a pulsating Dieulafoy lesion in the
distal jejunum.
Video 1 Colonoscopy-assisted placement of a 14/6 t over-the-scope clip to treat a bleeding
Dieulafoy lesion in the distal jejunum, with follow-up after 6 days showing ongoing
hemostasis.
The further clinical course was uneventful and the patient rapidly recovered without
restrictions. Endoscopic follow-up examination on day 6 after the procedure showed
ongoing hemostasis ([Fig. 2]).
Fig. 2 Endoscopic image showing ongoing hemostasis at follow-up examination on day 6 after
application of the over-the-scope clip for a jejunal Dieulafoy lesion.
In conclusion, severe small-intestinal bleeding is a rare event that is often associated
with a complex clinical course and a high mortality [1]. The presented case with an arterial bleeding Dieulafoy lesion, type 2b (Yamamoto
classification) is typically found in patients with cardiovascular risk factors [2]
[3]. It was previously shown that first- and second-line treatment with the OTSC in
non-variceal upper GI bleeding is a highly effective alternative strategy to surgery
and other endoscopic techniques [4]. To the best of our knowledge, this case provides the first evidence that application
of a 14/6 t OTSC is technically safe and effective in the treatment of Dieulafoy lesions
in the distal jejunum of selected patients.
Endoscopy_UCTN_Code_TTT_1AQ_2AZ
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