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• W3211133073 abstract "Introduction: Approximately 70% of dieulafoy lesions (DLs) of the upper gastrointestinal tract are found in the stomach within 6 cm of the gastro-esophageal junction. Periampullary DLs make up less than 2% of all obscure GI bleeding and present a significant diagnostic and therapeutic challenge. We present an obscure upper GI bleed (UGIB) that was diagnosed as a periampullary DL and treated with bipolar cauterization via duodenoscope. Case Description/Methods: A 68-year-old male with coronary artery disease and atrial fibrillation on apixaban presented to the ED with one week of melena and lightheadedness. He was found to have a hemoglobin of 9.8 g/dL decreased from 13.1 g/dL. An upper endoscopy was performed showing blood in the duodenum which was absent after irrigation. Multiple large and eroded gastric polyps were removed via cold snare polypectomy. He remained stable after polypectomy and was discharged on a proton pump inhibitor (PPI). He returned to the ED one week later for persistent melena and dyspnea. Repeat upper endoscopy did not show active bleeding at gastric polypectomy sites, but again showed blood in the second portion of the duodenum. A colonoscope was inserted and visualized spontaneous bright red blood lateral to the ampulla without surrounding mucosal ulceration or erosion. Non-bloody bile was observed from the ampulla making hemosuccus unlikely (Figure 1A-B). Diagnosis of a periampullary DL was made and treated with subcutaneous epinephrine injection and coaptive cauterization (Figure 1C) via duodenoscope. Hemostasis was obtained and he was discharged 24 hours later on PPI therapy. Two month follow up endoscopy showed stability at the cauterized periampullary DL site. Discussion: Periampullary DLs are a rare cause of UGIBs and present unique diagnostic and therapeutic challenges due to their anatomical location as traditional upper endoscopes may not visualize the ampulla. Gastric polyps may be incidentally found in 7% of UGIBs, but are rarely the primary source of bleeding as was the case in our patient. There is no current consensus on how to best treat periampullary DLs, yet standard hemostasis techniques including subcutaneous epinephrine, argon plasma or bipolar cautery can be considered with care as to not impair biliary drainage. More data is required to facilitate guideline-directed diagnostic and therapeutic criteria for these obscure and potentially lethal sources of UGIBs.Figure 1.: Image through a GIF (GIF-HQ190) showing bright red blood in the periampullary region. B: Image after switching GIF scope to a PCF (PCF-H190DL) clearly showing bleeding lateral to the ampulla which shows non-bloody bilious drainage suggestive of a DL. C: DL after successful treatment with subcutaneous epinephrine injection and copative cauterization. Endoscopic interventions were performed with a side-viewing duodenoscope (TJF-Q180V) given difficult anatomical location." @default.
• W3211133073 created "2021-11-08" @default.
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• W3211133073 date "2021-10-01" @default.
• W3211133073 modified "2023-09-25" @default.
• W3211133073 title "S2281 Not the Bleed You Are Looking For: Periampullary Dieulafoy Lesion" @default.
• W3211133073 doi "https://doi.org/10.14309/01.ajg.0000782656.73568.0c" @default.
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