S3358 Dieulafoy Lesions: A Rare Case of Recurrence

INTRODUCTION: Dieulafoy lesions (DL) are thickened arteriole malformations commonly found in the stomach that account for less than 2% of acute gastrointestinal (GI) bleeds. Conventional treatment is endoscopic and rarely requires surgical intervention. The risk of recurrence is low, especially in previously treated patients. CASE DESCRIPTION/METHODS: A 59-year-old male with past medical significant for hypertension (HTN), previous DL treated with gastrectomy for recurrent bleeding and multiple packed red blood cell (pRBC) transfusion 18 years ago presented for evaluation of palpitations. Review of system was positive for melena and lightheadedness with unremarkable physical examination. The patient was not on anticoagulation or anti-platelet agents. Laboratory test resulted in a hemoglobin (Hgb) of 8 g/dL. Upper endoscopy revealed non-bleeding ulcers in the stomach and colonoscopy revealed three polyps with no obvious source of bleeding. Hgb continued to trend downward and patient required multiple pRBC transfusions. Capsule endoscopy was performed at discharged, but patient was readmitted for a repeat episode of melena. Result of the capsule endoscopy revealed a clot in stomach with active bleeding in duodenum. Repeat endoscopy showed a DL in the proximal stomach which required placement of three clips to control the hemorrhage. Patient was discharged on omeprazole with no recurrent symptoms. DISCUSSION: DL are arterioles with thickened caliber that can protrude through a defect in the submucosal base without signs of ulceration. The pathogenesis is not clear, but likely secondary to a congenital abnormality of the blood vessels or a thrombotic event of the arteriole causing necrosis. The distribution of DL is equal in all ages but has a male predominance. Risk factors include heart disease, use of anticoagulants or anti-platelet agents and alcohol exposure; However, the mechanism by which they exert their effect is controversial. Surgery was the preferred treatment for DL, but now is less common with more endoscopic techniques available. Our patient had few risk factors that could have led to his original lesions, such as HTN and daily alcohol use. The risk of recurrence following endoscopic treatment is less than 9% and less with surgical resection, which would suggest another underlying contributing factor. DL need to be included in the differential diagnosis for GI bleeding, even in previously treated patients, given there are underlying factors that have yet to be elicited contributing to recurrence.