Endoscopic management of bleeding Dieulafoy-like lesion at hepaticojejunal anastomosis

This case describes a 64-year-old man with a history of total pancreatectomy, duodenectomy, and total gastrectomy for pancreatic cancer. He previously underwent reconstruction with esophagojejunal anastomosis and hepaticojejunal anastomosis, without Roux-en-Y. Arterial bridges of the superior mesenteric artery and the celiac trunk were performed, for which he received permanent antiplatelet therapy; he also uses oral anticoagulants to treat a deep vein thrombosis of the right upper extremity related to a central venous catheter. The patient presented with melena and acute anemia. Computed tomography angiography showed dense content in the small bowel with no evidence of active bleeding. It was decided to do an upper endoscopy ([Video 1]).

Video 1 Endoscopic management of jejunal hemorrhage.

In the mucosa surrounding the hepaticojejunal anastomosis, three vascular lesions were observed ([Fig. 1 a]), with enhanced visualization achieved with linked color imaging ([Fig. 1 b]) and blue laser imaging ([Fig. 1 c]). Two of the lesions were compatible with angioectasias, and the third was compatible with a cirsoid aneurysm, which presented a visible vessel with red stigmata.

Fig. 1 Endoscopic views of the hepaticojejunal anastomosis showing perianastomotic neoformation of blood vessels. a White-light mode. b Linked color imaging mode. c Blue laser imaging mode. d Hemoclip placement to the perianastomotic newly formed blood vessels and their tributaries.

It was decided to treat the lesion with argon plasma coagulation (APC), which caused active bleeding. Two clips were placed to achieve hemostasis. More clips were placed on the surrounding mucosa to treat the arteriolar vessels causing the lesion ([Fig. 1 d]).

The patient recovered with no new episodes of gastrointestinal bleeding, and was discharged on the third day.

Dieulafoy’s lesions in the jejunum are rare (1 %) [1]. In this case, there was doubt about the origin of the lesion; it could have been related to neoformation of blood vessels or varicose veins [2].

Diagnosis and treatment can be performed endoscopically in most cases [3], and a lower rate of rebleeding has been reported using combined endoscopic therapies [4]. Use of APC to treat angiodysplasia around the hepaticojejunal anastomosis has been reported previously [5].

Endoscopy_UCTN_Code_CCL_1AZ_2AO

Publication History

Article published online:
04 February 2022

• References

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