Exsanguinating jejunal Dieulafoy’s hemorrhage: how failed embolization guided life-saving resection – a case report

Abstract

Introduction and importance:

Dieulafoy’s lesion is a rare but severe cause of gastrointestinal bleeding. It is characterized by an aberrant submucosal arteriole eroding through the gastrointestinal mucosa, typically causing sudden, painless, and massive gastrointestinal hemorrhage that may present with intermittent, recurrent bleeding episodes. We report a case of hemorrhagic shock secondary to massive gastrointestinal bleeding caused by a jejunal Dieulafoy’s lesion.

Case presentation:

A 31-year-old female without significant medical comorbidities acutely developed recurrent, high-volume hematochezia and hypotensive shock. She was hemodynamically unstable with a hemoglobin level of 35 g/l upon admission. After hemodynamic stabilization and transfusion, endoscopy failed to localize the bleeding source, which was later identified in the jejunum by angiography. Selective arterial embolization was implemented but failed to achieve hemostasis. Consequently, exploratory laparotomy with segmental jejunal resection of the Dieulafoy’s lesion was performed. The patient demonstrated satisfactory recovery and was discharged on the fifth postoperative day.

Clinical discussion:

Jejunal Dieulafoy’s lesion is an exceedingly rare cause of gastrointestinal bleeding, accounting for merely 1% of all Dieulafoy’s lesions. Diagnosis is challenging due to the inaccessibility of jejunum with conventional endoscopy and the intermittent nature of hemorrhage. Angiographic embolization is effective for active bleeding when endoscopic therapy fails. Surgery remains an option when other interventions are unsuccessful, particularly in hemodynamically unstable patients.

Conclusion:

Jejunal Dieulafoy’s lesion, though rare, is a potentially life-threatening cause of gastrointestinal hemorrhage that demands prompt diagnosis and intervention. A multidisciplinary approach – combining endoscopic therapy, angiography, and surgery – significantly enhances clinical outcomes.

Introduction

Dieulafoy’s lesion was first described by Gallard in 1884 and was subsequently characterized in detail by Paul Georges Dieulafoy, who termed it “exulceratio simplex” in 1898[1]. Dieulafoy’s lesion is a rare and important cause of gastrointestinal hemorrhage. It is characterized by an aberrant submucosal arteriole eroding through the gastrointestinal mucosa and resulting in gastrointestinal bleeding. Dieulafoy’s lession can occur in the entire gastrointestinal tract, mostly found in stomach. Jejunal Dieulafoy’s lesion represents an exceptionally rare etiology of gastrointestinal hemorrhage that may lead to life-threatening exsanguination. Recent studies demonstrate that merely 1% of all confirmed cases of Dieulafoy’s lesion are found in jejunum[2]. This case report highlights the Exsanguinating caused by the jejunal Dieulafoy’s lesion in a 31-year-old female. She underwent the angiographic embolization failed to achieve hemostasis and finally exploratory laparotomy and the resection with segmental jejunal resection of the Dieulafoy’s lesion was performed.

HIGHLIGHTS

• Rare case presentation: Reports a life-threatening jejunal Dieulafoy’s lesion (representing only 1% of cases) causing hemorrhagic shock in a young patient.

• Diagnostic challenge: Demonstrates the limitations of conventional endoscopy in jejunal bleeding localization, highlighting angiography’s critical diagnostic role.

• Treatment algorithm: Illustrates the therapeutic sequence from failed embolization to successful surgical resection, providing a management paradigm for similar cases.

• Clinical significance: Emphasizes the need for prompt multidisciplinary intervention (endoscopic, angiographic, and surgical) in rare but catastrophic small bowel hemorrhages.

• Outcome data: Documents successful surgical resolution after endovascular failure, contributing to the limited literature on jejunal Dieulafoy’s lesion management.

This case report has been written in line with the SCARE Guidelines (Surgical CAse REport Guidelines)[3].

Case presentation

A 31-year-old nulliparous woman with no prior medical history presented with acute-onset non-bloody vomiting of gastric contents followed by massive hematochezia and syncopal episodes. The patient denied any precipitating factors including NSAID use, alcohol consumption, or trauma history. There was no report of hematemesis, abdominal pain, or prior gastrointestinal symptoms. Notably, she had no personal or family history of bleeding disorders or coagulopathies, and was not taking any anticoagulant medications.

On admission to our emergency department, the patient appeared pale and agitated. Physical examination revealed a soft, non-tender abdomen without rebound tenderness. Cardiovascular, respiratory, and neurological examinations were unremarkable. Vital signs included tachycardia (102 bpm), hypotension (102/46 mm Hg), and normal oxygen saturation (99% on room air). Laboratory studies demonstrated persistent severe anemia (HGB 35 g/l) and mild leukocytosis (WBC 11.5 × 10⁹/l).

Despite aggressive resuscitation with 1200 ml packed red blood cells and 300 ml fresh frozen plasma, she remained hemodynamically unstable with only partial hemoglobin recovery to 74 g/l and continued active bleeding. Comprehensive endoscopic evaluation, including both gastroscopy and colonoscopy, failed to identify the bleeding source. Pharmacological hemostatic measures were ineffective, with persistent episodes of profuse hematochezia containing blood clots and recurrent syncope necessitating prompt diagnosis and treatment.

Within hours, the patient developed hemodynamic instability with deteriorating consciousness and hemoglobin levels dropping to 30 g/l, necessitating emergent endotracheal intubation. The patient immediately underwent blood transfusion and fluid resuscitation. Initial diagnostic workup including non-contrast CT scans of the chest, abdomen, and pelvis failed to identify the bleeding source.

Diagnostic angiography revealed active extravasation from a branch of the superior mesenteric artery with contrast leakage into the intestinal lumen (Fig. 1). Selective catheterization was performed, and two 2 cm ×2 mm coils were deployed for therapeutic embolization. However, recurrent hematochezia with blood clots persisted post-embolization.

Figure 1.

Diagnostic angiography revealed active extravasation from a branch of the superior mesenteric artery with contrast leakage into the intestinal lumen.

Exploratory laparotomy demonstrated significant hemoperitoneum within the small intestinal lumen. During meticulous manual exploration, the implanted microcoils were palpated approximately 100 cm distal to the ligament of Treitz along the mesenteric vascular arcade, their characteristic metallic firmness providing distinct tactile contrast to the surrounding bowel wall. Surgical enterotomy revealed active arterial bleeding with intermittent pulsatile flow originating from the mesenteric border of the jejunal mucosa (Fig. 2). The definitive surgical treatment consisted of segmental resection of the involved jejunum, including a 15-cm segment containing the bleeding site, followed by creation of a functional end-to-end anastomosis. The resected specimen was submitted for histopathological evaluation, which subsequently confirmed the diagnosis of a jejunal Dieulafoy’s lesion (Fig. 3). Postoperatively, the patient was transferred to the surgical intensive care unit for continued ventilator support and hemodynamic monitoring. The patient was transferred to the general ward after 24 hours of intensive care unit (ICU) monitoring and was subsequently discharged on postoperative day 5 following an uncomplicated recovery.

Figure 2.

The photograph demonstrates a resected jejunal segment harboring a Dieulafoy’s lesion, where the finger indicates the site of pathology.

Figure 3.

Hematoxylin and eosin-stained microscopic sections of the resected jejunal Dieulafoy’s lesion demonstrated a large-caliber submucosal artery.

Discussion

Dieulafoy lesions may arise in any segment of the gastrointestinal tract, with the highest prevalence in the stomach (72%), followed by the duodenum (15%), esophagus (8%), colon (2%), and jejunum-ileum (1%)[4]. jejunal Dieulafoy’s lesion is a rare yet clinically significant cause of gastrointestinal hemorrhage, which can lead to life-threatening, torrential bleeding. In this case, the patient presented with high-volume hematochezia and hypovolemic syncope. The lesion presents diagnostic challenges due to its diminutive size, anatomical inaccessibility to standard endoscopic examination, and obscuration by intraluminal blood accumulation and/or subsequent clot formation. Furthermore, no established treatment consensus currently exists. Therefore, timely diagnosis and therapeutic intervention are critical for optimizing clinical outcomes.

The incidence of jejunal Dieulafoy’s lesion was slightly higher in male patients than in females, with a male-to-female ratio of 1.2:1. A wide age variation was observed, ranging from 10 to 95 years (mean ± standard deviation, 55 ± 24 years; median, 82 years).Advanced age was associated with an increased risk of disease development. Due to the elderly patient population and potential underlying chronic comorbidities, the use of anticoagulants and nonsteroidal anti-inflammatory drugs (NSAIDs) may influence disease progression^[2,5^]. However, no such medication use was documented in the present case.

The clinical presentation of jejunal Dieulafoy’s lesion primarily manifests as gastrointestinal bleeding, including melena and hematochezia. The most characteristic feature is acute painless bleeding, which can occasionally lead to massive hemorrhage, resulting in hemodynamic instability such as tachycardia, hypotension, and even syncope[6]. This case presented with massive hematochezia accompanied by hemorrhagic shock. Due to the absence of established management guidelines, diagnostic and therapeutic approaches must be tailored according to variations in clinical manifestations, hemorrhage severity, and hemodynamic stability.

The diagnosis of jejunal Dieulafoy’s lesion poses significant clinical challenges. Conventional endoscopy has limited accessibility to the jejunal lumen, while intraluminal blood clots frequently obscure the underlying lesions, further complicating visualization[7]. In hemodynamically stable patients, both capsule endoscopy and push enteroscopy may be employed as diagnostic modalities, albeit with variable diagnostic yields. For cases presenting with hemodynamic instability, mesenteric angiography emerges as a crucial diagnostic intervention. The recent study revealed a mean of 3 diagnostic attempts (range: 1–11) required to identify jejunal pathology[2]. In this case, conventional endoscopic approaches (gastroscopy and colonoscopy) failed to identify the bleeding source. Subsequent angiography demonstrated active extravasation from a jejunal branch vessel, confirming a Dieulafoy’s lesion in the jejunum.

The management of jejunal Dieulafoy’s lesions encompasses three primary modalities: endoscopic therapy, surgical intervention, and angiographic embolization. Endoscopic approaches are preferred for hemodynamically stable patients. When endoscopic intervention fails, angiographic embolization is the preferred alternative for patients who are poor surgical candidates. In the present case, we employed this approach given its dual diagnostic and therapeutic value in managing this condition. Recent case reports have documented instances where transarterial embolization failed to achieve durable hemostasis^[8,9^]. In the present case, recurrent hemorrhage occurred following angiographic embolization, necessitating emergent laparotomy. Intraoperative identification of jejunal Dieulafoy’s lesions remains particularly challenging due to the absence of characteristic fibrotic changes, inflammatory markers, polypoid formations, or overt mucosal abnormalities, underscoring the critical importance of preoperative localization for successful surgical resection[10]. In the present case, despite unsuccessful angiographic embolization, manual palpation of the implanted microcoils along the mesenteric vascular arcade enabled precise localization of the bleeding site, serving as an effective alternative to intraoperative endoscopy. Surgical intervention becomes imperative when alternative diagnostic modalities prove unsuccessful, particularly in hemodynamically unstable patients. Surgical intervention is indicated when endoscopic and angiographic therapies fail, particularly in hemodynamically unstable patients. Although surgery offers definitive treatment with low rebleeding rates, it should be reserved for refractory cases and guided by preoperative or intraoperative localization.

Conclusion

jejunal Dieulafoy’s lesion represents a rare yet clinically significant vascular anomaly that continues to pose diagnostic challenges. Optimal management requires careful consideration of both the suspected lesion location within the jejunum and the patient’s hemodynamic stability when selecting initial therapeutic interventions. A multidisciplinary approach incorporating endoscopic, angiographic, and surgical modalities has been shown to optimize treatment outcomes. This report emphasizes the importance of developing individualized diagnostic and therapeutic strategies for this condition in clinical practice.

Ethical approval

Ethical approval is not applicable/waived at our institution.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review from the Editor-in-Chief of this journal on request.

Sources of funding

None.

Author contributions

I am the sole author of this manuscript. I hereby confirm that I have conceived the study, collected and analyzed the data, interpreted the findings, written the manuscript in its entirety, and approved the final version for submission.

Conflicts of interest disclosure

The author has no conflicts of interest to disclose.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Hu Chaojie.