Title: The Elusive Source: Mid-Jejunal Dieulafoy Lesion Causing Recurrent GI Bleed Despite Initial Negative Multimodal Workup

Author(s): Pasang Sherpa, MD; Lili O’Brien, MD; Raagini Gupta, MD; Timothy J.Barreiro, DO

First Author Email: psherpa@mercy.com

Institution: SEYH

Residency: Internal Medicine

Introduction: A Dieulafoy lesion (DL) is a dilated, aberrant submucosal artery that erodes the overlying epithelium without a primary ulcer, accounting for approximately 1-2% of all acute GI bleeding episodes. While stomach is the most common site, extragastric lesions occur but are rare; jejunal lesions, specifically, represent only about 1% of reported cases. We present a case of an elderly male with a mid-jejunum DL who required massive blood transfusion and repeated thorough investigations before the source was identified.

Case Report: A 64-year-old male with a history of prostate cancer (s/p radiation and prostatectomy), hypertension, and hyperlipidemia presented with hematochezia and syncope. CT angiography suggested active bleeding in the mid-jejunum. However, interventional radiology (IR) guided angiograms and initial esophagogastroduodenoscopy (EGD) failed to identify active bleeding despite extensive search. A nuclear medicine scan suggested a small focus of gastric bleeding, yet urgent repeat IR angiogram, push enteroscopy, and colonoscopy remained non-diagnostic. The patient developed recurrent hemorrhagic shock requiring intensive care. Video capsule endoscopy (VCE), a modality recommended for suspected small bowel bleeding, eventually visualized a small polypoid lesion in the jejunum. Repeat endoscopy identified a fresh blood clot with underlying red spots in the mid-jejunum consistent with a DL. The patient received a total of 28 units of blood before being discharged in stable condition.

Discussion/Conclusion: Dieulafoy lesions are challenging to diagnose and may not be identified in up to 30% of initial endoscopic procedures. The lesion is often small and surrounded by normal-appearing mucosa, making it easily missed if not actively bleeding. Because the bleeding is often intermittent, repeated endoscopic evaluations are frequently necessary to visualize the aberrant vessel or active spurting. In cases of obscure bleeding where standard endoscopy is negative, VCE serves as a critical diagnostic tool for visualizing the small bowel. Failure to diagnose DL can lead to recurrent massive hemorrhage and high mortality rates.