A 58-year-old man with history of diabetes, hypertension, chronic kidney disease,
and chronic calcific pancreatitis presented with five episodes of coffee-ground emesis
and melena. The patient had previously required endoscopic transmural drainage of
walled-off pancreatic necrosis 1 year earlier with a lumen-apposing metal stent, which
had since been removed.
The patient presented with tachycardia with a heart rate of 125 beats/minute and blood
pressure was 107/75 mmHg. Laboratory examination revealed hemoglobin of 6.8 g/dL (baseline
level of 13 g/dL). Upper endoscopy with a forward-viewing gastroscope with a distal
attachment cap revealed blood in the second part of the duodenum as well as a clot
in the area of the major papilla ([Fig. 1]). Due to concern for hemosuccus pancreaticus from a bleeding pseudoaneurysm, a computed
tomography angiogram was performed, which did not demonstrate a pseudoaneurysm or
any active bleeding. Subsequent examination with a duodenoscope revealed a pulsatile
vessel ([Fig. 2], [Video 1]) in the absence of an ulcer, confirming the diagnosis of a Dieulafoy’s lesion at
the major papilla, which was clearly separate from the bile duct and pancreatic duct
orifices.
Fig. 1 Clot at the major papilla adjacent to the bile duct orifice.
Fig. 2 Actively bleeding Dieulafoy’s lesion.
Video 1 Identification and treatment of Dieulafoy’s lesion at the major papilla.
Endoscopic therapy with epinephrine injection and bipolar cautery was successful in
treating the lesion ([Fig. 3]).
Fig. 3 Dieulafoy’s lesion after endoscopic treatment.
Defined as dilated aberrant submucosal vessels eroding through overlying epithelium
without ulceration, Dieulafoy’s lesions can present anywhere along the gastrointestinal
tract [1]. Typically located in the proximal stomach, Dieulafoy’s lesions are exceedingly
rare at the major papilla with few reported cases at this location [2]. Risk factors for the development of Dieulafoy’s lesions include male sex, hypertension,
chronic kidney disease, and diabetes, all of which were noted in this patient [1]. Additional differential diagnoses in this patient would include hemosuccus pancreaticus
from a pseudoaneurysm or gastric varices secondary to splenic vein thrombosis [3].
Endoscopy_UCTN_Code_TTT_1AO_2AD
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