The rare finding of a Dieulafoy’s lesion at the major papilla

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

Competing interests

Dr. Wagh declares he is a consultant for Boston Scientific and Medtronic. Dr. Wani declares he is a consultant for Boston Scientific, Medtronic, Interpace and Cernostics, and is supported by the University of Colorado Department of Medicine Outstanding Early Scholars Program. Dr. Han declares no conflict of interest.

• References

• 1 Lara LF, Sreenarasimhaiah J, Tang SJ. et al. Dieulafoy lesions of the GI tract: localization and therapeutic outcomes. Dig Dis Sci 2010; 55: 3436-3441
• 2 Han D, Adler ME, Sejpal DV. Ampullary Dieulafoy: an unusual cause of obscure gastrointestinal bleeding. Clin Gastroenterol Hepatol 2018; 16: A31
• 3 Savastano S, Feltrin GP, Antonio T. et al. Arterial complications of pancreatitis: diagnostic and therapeutic role of radiology. Pancreas 1993; 8: 687-692

Publication History

Article published online:
05 June 2020