Home Print this page Email this page Users Online: 322
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
LETTER TO THE EDITOR
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 177-178

Endoscopic hemostasis of a bleeding diverticular Dieulafoy's lesion in the third portion of duodenum


1 Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, USA
2 Department of Medicine, Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
3 Department of Medicine, Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences and the Central Arkansas Veterans Healthcare System, Little Rock, AR, USA

Date of Submission07-Sep-2021
Date of Acceptance05-Apr-2022
Date of Web Publication21-Apr-2022

Correspondence Address:
Anastasiou Jiannis
Department of Medicine, Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences and the Central Arkansas Veterans Healthcare System, Little Rock, AR
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjmms.sjmms_523_21

Rights and Permissions

How to cite this article:
Anam H, Abhilash P, Sumant I, Jiannis A. Endoscopic hemostasis of a bleeding diverticular Dieulafoy's lesion in the third portion of duodenum. Saudi J Med Med Sci 2022;10:177-8

How to cite this URL:
Anam H, Abhilash P, Sumant I, Jiannis A. Endoscopic hemostasis of a bleeding diverticular Dieulafoy's lesion in the third portion of duodenum. Saudi J Med Med Sci [serial online] 2022 [cited 2022 Oct 3];10:177-8. Available from: https://www.sjmms.net/text.asp?2022/10/2/177/343722



Diverticula of the gastrointestinal (GI) tract are commonly found in the colon. Duodenal diverticula are rare (prevalence of <1%), usually asymptomatic, and frequently located in the second portion. Although infrequent, duodenal diverticula can have significant associated morbidity: mechanical obstruction of the common bile duct, pancreatic duct and duodenum, diverticulitis with perforation, abscess, fistula formation, and hemorrhage.[1]

A handful of cases have been reported in the literature describing patients with duodenal diverticulum presenting as gastrointestinal bleed. Few of these are in the third[2] or fourth[3] portions of the duodenum. Diagnosis in these patients may be difficult, as endoscopic visualization may not be possible by using the regular front-view esophagogastroduodenoscope. A side-viewing endoscopic retrograde cholangiopancreatography scope or colonoscope may be required. Imaging using upper GI barium series and/or computed tomography angiography may also be beneficial. Various surgical treatment options have been described previously including open and laparoscopic diverticulectomy.[4],[5]

Two cases have been reported using combined endoscopy followed by surgery and endoscopy plus interventional radiology guided coiling for diverticular bleed in the second[6] and third[7] portions of the of duodenum, respectively. Here, we describe the case of an actively bleeding diverticular dieulafoy lesion in the third portion of the duodenum with successful endoscopic hemostasis as a sole intervention modality.

A 76-year-old Caucasian male with hypertension, type II diabetes mellitus, and end-stage renal disease presented to the hospital due to melena for 7 days. He was taking a low-dose aspirin but no anticoagulants. He had no history of prior bowel surgeries or GI bleed, denied any alcohol or tobacco use, or of any nonsteroidal anti-inflammatory drugs. On presentation, he was hemodynamically stable with a blood pressure of 100/70 mmHg, heart rate of 94 beats/min and afebrile with an oxygen saturation of 100% at room air. Blood work showed a hemoglobin of 6.5 g/dL (baseline 9 g/dL), blood urea nitrogen 62 mg/dL (baseline 30–35 mg/dL), platelets of 155,000/mL, serum creatinine of 4.3 mg/dL, INR of 1.4. Imaging with computed tomography scan of the abdomen without contrast showed a duodenal diverticulum with no active extravasation into the GI lumen. Upper endoscopy with adult gastroscope showed normal esophagus, stomach with altered blood and a duodenal diverticulum in the third portion with food debris [Figure 1]. Given the location, a pediatric colonoscope was used next. After the removal of the food particles, an adherent clot was seen at the base of the diverticulum. The clot was dislodged with aggressive irrigation, and subsequently, a bleeding Dieulafoy's lesion was seen. Successful hemostasis was achieved with two metal clips [Figure 2].
Figure 1: Bleeding Dieulafoy's lesion inside a duodenal diverticulum

Click here to view
Figure 2: Endoscopic treatment of bleeding Dieulafoy's lesion inside a duodenal diverticulum

Click here to view


To our knowledge, only one similar case has been reported previously in Japan. An 80-year-old man presented with upper GI bleed. Endoscopy showed a diverticulum in the third portion of the duodenum with an adherent clot. The clot was removed using a hood applied at the tip of the endoscope and a snare. An underlying Dieulafoy lesion was treated endoscopically with hemostasis clips.[8]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the Journal. The patient understands that his name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Afridi SA, Fichtenbaum CJ, Taubin H. Review of duodenal diverticula. Am J Gastroenterol 1991;86:935-8.  Back to cited text no. 1
    
2.
Avalos-González J, Zaizar-Magaña A. Duodenal diverticulum in the third portion of duodenum as a cause of upper gastrointestinal bleeding and chronic abdominal pain. Case report and literature review. Cir Cir 2008;76:65-9.  Back to cited text no. 2
    
3.
Rioux L, Des Groseilliers S, Fortin M, Mutch DO. Massive upper gastrointestinal bleeding originating from a fourth-stage duodenal diverticulum: A case report and review of the literature. Can J Surg 1996;39:510-2.  Back to cited text no. 3
    
4.
Ruiz-Tovar J, Sáinz R, Sanjuanbenito A, Martínez Molina E. Fourth-portion duodenal diverticulum causing massive upper gastrointestinal bleeding. Am Surg 2008;74:27-8.  Back to cited text no. 4
    
5.
Dan D, Bascombe N, Maharaj R, Hariharan S, Naraynsingh V. Laparoscopic diverticulectomy for massive hemorrhage in a duodenal diverticulum. Surg Laparosc Endosc Percutan Tech 2012;22:e39-41.  Back to cited text no. 5
    
6.
Callery MP, Aliperti G, Soper NJ. Laparoscopic duodenal diverticulectomy following hemorrhage. Surg Laparosc Endosc 1994;4:134-8.  Back to cited text no. 6
    
7.
Wilhelmsen M, Andersen JF, Lauritsen ML. Severe upper gastrointestinal bleeding in extraluminal diverticula in the third part of the duodenum. BMJ Case Rep 2014;2014:bcr2013202516.  Back to cited text no. 7
    
8.
Ogasawara N, Kikuchi D, Tanaka M, Matsui A, Iizuka T, Hoteya S. Hemostasis achieved endoscopically for duodenal diverticular bleeding by removing a large blood clot using a snare. Clin J Gastroenterol 2020;13:615-20.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   References
   Article Figures

 Article Access Statistics
    Viewed786    
    Printed27    
    Emailed0    
    PDF Downloaded89    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]