P2581 - A Tortuous Journey Through the Treatment of a Rare Upper Gastrointestinal Bleed; A Case Report of Hemorrhagic Shock from a Dieulafoy Lesion and the Interdisciplinary Orchestration of Management

Allyson Hunt, MD¹, Jay M. Patel, DO¹, Amy Rechenberg, MD², Eric Lee, MD³, Malik Khan, MD, MBBS^4
1Spectrum Health Graduate Medical Education, Grand Rapids, MI; ²Spectrum Health, Grand Rapid, MI; ³Spectrum Health, Grand Rapids, MI; ⁴Spectrum Health Medical Group, Grand Rapids, MI

Introduction: A Dieulafoy lesion (DL) is described as a single, large-caliber, tortuous and malformed arteriole that is thought to erode up from the submucosal layer and lead to sudden unprovoked bleeding and the appearance makes identification a diagnostic challenge. Lesions typically arise in the lesser curvature of the stomach but can be found throughout the gastrointestinal tract. Endoscopic treatment is preferred but DLs have the potential to quickly escalate and cause shock in rare cases.

Case Description/Methods: We present a previously healthy 57-year-old male who arrived to the hospital after two syncopal episodes following a large melanotic stool. On presentation, he was hypotensive with continued vasovagal episodes. Esophagogastroduodenoscopy (EGD) revealed a large thrombus in the stomach without a clear source. With multiple episodes of hematochezia upon admission and associated hypotension, he was transferred to the ICU. He was started on multiple pressors and required massive transfusion. At that time, Interventional Radiology (IR) and Emergency General Surgery (EGS) were notified of the patient. IR performed an emergent embolization with brief stabilization but shortly after, the patient again required multiple pressors and repeat massive transfusion. With increasing abdominal distention and elevated peak pressures on the ventilator, EGS was called for continued instability and abdominal compartment syndrome. He was taken immediately for exploratory laparotomy with gastrotomy resulting in removal of several liters of blood. The source was identified and consistent with a DL that was controlled with suture ligation and forty-nine total units of blood prior to discharge home.

Discussion: DLs have a prevalence of less than 1% and can lead to high rates of mortality in the setting of hemorrhagic shock, if unrecognized. Given the low prevalence and lack of understanding regarding the etiology and pathogenesis, this case illustrates the importance of maintaining a high level of suspicion along with utilization of a multi-disciplinary approach in the setting of overt GI bleeds. The first diagnostic step begins with minimally invasive endoscopic evaluation, however hemodynamic instability necessitates escalation of care by exploring additional therapeutic interventions, including surgical salvage. Although various therapeutic modalities exist for management, early lesions can go endoscopically undetected, and a prompt interdisciplinary approach can save a patient’s life.


Figure: Bleeding lesion identified during Interventional Radiology catheterization with angiography and coil embolization. Brisk extravasation noted originating from gastric fundus taking supply from short gastric artery and left gastric artery.


Disclosures:
Allyson Hunt indicated no relevant financial relationships.
Jay Patel indicated no relevant financial relationships.
Amy Rechenberg indicated no relevant financial relationships.
Eric Lee indicated no relevant financial relationships.
Malik Khan indicated no relevant financial relationships.


Allyson Hunt, MD¹, Jay M. Patel, DO¹, Amy Rechenberg, MD², Eric Lee, MD³, Malik Khan, MD, MBBS⁴. P2581 - A Tortuous Journey Through the Treatment of a Rare Upper Gastrointestinal Bleed; A Case Report of Hemorrhagic Shock from a Dieulafoy Lesion and the Interdisciplinary Orchestration of Management, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.