Hidden in the Small Bowel: A Case of Ileal Dieulafoy's Lesion

Case Description

A 48-year-old woman with no comorbidities presented with maroon stools for 3 weeks. She denied any previous GI bleed, alcohol or smoking consumption, or bleeding disorders. The patient has not been on nonsteroidal anti-inflammatory drugs, antiplatelets, anticoagulants, or corticosteroids. Prior esophagogastroduodenoscopies were inconclusive, though colonoscopy showed blood in the colon and ileum without a source. She required multiple blood transfusions; her hemoglobin was 40 g/L, white blood cell count was 9.9 × 10⁹/L, platelet count was 302 × 10⁹/L, and serum urea was 16.8 mmol/L. Other laboratory parameters and imaging were unremarkable. Repeat esophagogastroduodenoscopy was normal, and repeat colonoscopy again revealed only intraluminal blood. Computed tomography angiography was negative. Capsule endoscopy localized bleeding to the proximal ileum. Double-balloon enteroscopy (DBE) identified an actively bleeding large submucosal artery in the proximal ileum, 240 cm from the gastroduodenal junction, consistent with DL ([Figs. 1] and [2]). Endoscopic hemostasis was achieved with a dual-modality approach—epinephrine injection (1:10,000 dilution, 2 mL aliquots circumferentially) to reduce active spurting and improve visualization, followed by deployment of single through-the-scope hemoclip across the bleeding point to mechanically occlude the vessel ([Fig. 3]). The patient had no recurrence of bleeding, avoided surgery, and remains well at 12-month follow-up.

Fig. 1 Figure showing Dieulafoy's lesion in proximal ileum.

Fig. 2 Figure showing active bleed from the lesion.

Fig. 3 Hemoclip application for hemostasis.

 

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Practical Implications for Endoscopists

• Maintain high suspicion for DL in obscure GI bleeding.[1] [2]

• Consider small bowel DL—including ileal lesions—especially in recurrent, severe bleeding where initial endoscopy is unrevealing.[2]

• Use combination endoscopic therapy (e.g., epinephrine injection followed by mechanical clipping) as first-line for accessible DLs, which achieves hemostasis in approximately 90% of cases with < 10% early rebleeding.[3] [4] [5]

• Recognize limitations in detection, including small lesion size, intermittent bleeding, and poor visualization in lower GI tract; DBE improves diagnostic yield in small bowel cases.[1] [2] [5]

• Plan tiered management: repeat endoscopy or angiographic embolization for rebleeding, reserving surgery for refractory cases. Early diagnosis and timely intervention reduce morbidity and mortality.[5]

 

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Conflict of Interest

None declared.

• References

• 1 Lipka S, Rabbanifard R, Kumar A, Brady P. A single-center United States experience with bleeding Dieulafoy lesions of the small bowel: diagnosis and treatment with single-balloon enteroscopy. Endosc Int Open 2015; 3 (04) E339-E345
• 2 Dalal A, Patil G, Maydeo A. Outcomes of double balloon enteroscopy for managing overt small bowel bleeding. J Dig Endosc 2020; 11 (02) 118-125
• 3 Jeon HK, Kim GH. Endoscopic management of Dieulafoy's lesion. Clin Endosc 2015; 48 (02) 112-120
• 4 Cui J, Huang LY, Liu YX. et al. Efficacy of endoscopic therapy for gastrointestinal bleeding from Dieulafoy's lesion. World J Gastroenterol 2011; 17 (10) 1368-1372
• 5 Levy AR, Broad S, Loomis Iii JR, Thomas JA. Diagnosis and treatment of a recurrent bleeding Dieulafoy's lesion: a case report. Cureus 2022; 14 (11) e32051

Publication History

Article published online:
08 September 2025