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Successful side-viewing endoscopic hemoclipping for Dieulafoy-like lesion at the brim of a periampullary diverticulum.

Lee WS, Cho SB, Park SY, Park CH, Joo YE, Kim HS, Choi SK, Rew JS - BMC Gastroenterol (2010)

Bottom Line: Massive bleeding often results from these lesions and can impede the accurate early treatment. 67 years old male patient suffered a fatal bleeding from Dieulafoy-like lesion located at the mouth of the periampullary diverticulum.Initial endoscopic therapy and radiologic embolization failed to stop the bleeding, while direct observation and hemoclipping by the side viewing endoscopy successfully established correct diagnosis and permanent cure of the lesion.Verification of the diagnosis and definitive treatment often needed repeated examination by side-viewing endoscope as well as stabilization of the patient.

View Article: PubMed Central - HTML - PubMed

Affiliation: LDepartment of Internal Medicine, Division of Gastroenterology, Chonnam Medeical University Hwasun Hospital, Hwasun, Jeonnam, South Korea. jadelook@hanmail.net

ABSTRACT

Background: Duodenal Dieulafoy's lesions are rare and only several cases were reported so far. Their characteristic appearance and location make it difficult to be diagnosed in the clinical practice. Massive bleeding often results from these lesions and can impede the accurate early treatment.

Case presentation: 67 years old male patient suffered a fatal bleeding from Dieulafoy-like lesion located at the mouth of the periampullary diverticulum. Initial endoscopic therapy and radiologic embolization failed to stop the bleeding, while direct observation and hemoclipping by the side viewing endoscopy successfully established correct diagnosis and permanent cure of the lesion.

Conclusion: Aggressive endoscopic examinations combined with the accurate endoscopic treatment should be adopted when Dieulafoy-like lesion is suspected as a possible cause of the proximal small bowel hemorrhage. Verification of the diagnosis and definitive treatment often needed repeated examination by side-viewing endoscope as well as stabilization of the patient.

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Initial manifestation and treatment. A. On duodenoscopic exam, at the margin of large(about 6 cm) periampullary diverticulum was a small exposed vascular turft emanating the spurting jet of blood. B. Epinephrine and saline mixture was injected to lessen the bleeding, but complete hemostasis was not achieved.
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Figure 1: Initial manifestation and treatment. A. On duodenoscopic exam, at the margin of large(about 6 cm) periampullary diverticulum was a small exposed vascular turft emanating the spurting jet of blood. B. Epinephrine and saline mixture was injected to lessen the bleeding, but complete hemostasis was not achieved.

Mentions: Urgent endoscopic examination(XQ-240; Olympus, Japan) revealed large clot and fresh blood at the descending portion of the duodenum but exact bleeding focus could not be found. Melena continued and the patient's condition deteriorated. On side-viewing duodenoscopy(TJF-240; Olympus, Japan) performed next day, spurting jet of blood was observed from the small vascular turft located at the margin of the large(about 6 cm in size) periampullary diverticulum (Figure 1). After Epinephrine and saline mixture (about 30 cc) was injected maginally to lessen the bleeding, angiography was tried to intervene the bleeding vessel directly. On celiac axis angiogram, there was a extravasation of contrast media from distal branch of gastroduodenal artery (Figure 2A). This branch was superselected and embolized with the five microcoils (Figure 2B). Bleeding seemed to be temporarily controlled, however, the patient sustained another bout of severe hematemesis following day.


Successful side-viewing endoscopic hemoclipping for Dieulafoy-like lesion at the brim of a periampullary diverticulum.

Lee WS, Cho SB, Park SY, Park CH, Joo YE, Kim HS, Choi SK, Rew JS - BMC Gastroenterol (2010)

Initial manifestation and treatment. A. On duodenoscopic exam, at the margin of large(about 6 cm) periampullary diverticulum was a small exposed vascular turft emanating the spurting jet of blood. B. Epinephrine and saline mixture was injected to lessen the bleeding, but complete hemostasis was not achieved.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2837224&req=5

Figure 1: Initial manifestation and treatment. A. On duodenoscopic exam, at the margin of large(about 6 cm) periampullary diverticulum was a small exposed vascular turft emanating the spurting jet of blood. B. Epinephrine and saline mixture was injected to lessen the bleeding, but complete hemostasis was not achieved.
Mentions: Urgent endoscopic examination(XQ-240; Olympus, Japan) revealed large clot and fresh blood at the descending portion of the duodenum but exact bleeding focus could not be found. Melena continued and the patient's condition deteriorated. On side-viewing duodenoscopy(TJF-240; Olympus, Japan) performed next day, spurting jet of blood was observed from the small vascular turft located at the margin of the large(about 6 cm in size) periampullary diverticulum (Figure 1). After Epinephrine and saline mixture (about 30 cc) was injected maginally to lessen the bleeding, angiography was tried to intervene the bleeding vessel directly. On celiac axis angiogram, there was a extravasation of contrast media from distal branch of gastroduodenal artery (Figure 2A). This branch was superselected and embolized with the five microcoils (Figure 2B). Bleeding seemed to be temporarily controlled, however, the patient sustained another bout of severe hematemesis following day.

Bottom Line: Massive bleeding often results from these lesions and can impede the accurate early treatment. 67 years old male patient suffered a fatal bleeding from Dieulafoy-like lesion located at the mouth of the periampullary diverticulum.Initial endoscopic therapy and radiologic embolization failed to stop the bleeding, while direct observation and hemoclipping by the side viewing endoscopy successfully established correct diagnosis and permanent cure of the lesion.Verification of the diagnosis and definitive treatment often needed repeated examination by side-viewing endoscope as well as stabilization of the patient.

View Article: PubMed Central - HTML - PubMed

Affiliation: LDepartment of Internal Medicine, Division of Gastroenterology, Chonnam Medeical University Hwasun Hospital, Hwasun, Jeonnam, South Korea. jadelook@hanmail.net

ABSTRACT

Background: Duodenal Dieulafoy's lesions are rare and only several cases were reported so far. Their characteristic appearance and location make it difficult to be diagnosed in the clinical practice. Massive bleeding often results from these lesions and can impede the accurate early treatment.

Case presentation: 67 years old male patient suffered a fatal bleeding from Dieulafoy-like lesion located at the mouth of the periampullary diverticulum. Initial endoscopic therapy and radiologic embolization failed to stop the bleeding, while direct observation and hemoclipping by the side viewing endoscopy successfully established correct diagnosis and permanent cure of the lesion.

Conclusion: Aggressive endoscopic examinations combined with the accurate endoscopic treatment should be adopted when Dieulafoy-like lesion is suspected as a possible cause of the proximal small bowel hemorrhage. Verification of the diagnosis and definitive treatment often needed repeated examination by side-viewing endoscope as well as stabilization of the patient.

Show MeSH
Related in: MedlinePlus