Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2000  |  Volume : 6  |  Issue : 1  |  Page : 56-58
Massive melena from a dieulafoy's type ulcer of the jejunum: A case report


1 Department of Surgery, Security Forces Hospital, Riyadh, Saudi Arabia
2 Department of Medicine, Security Forces Hospital, Riyadh, Saudi Arabia
3 Department of Pathology, Security Forces Hospital, Riyadh, Saudi Arabia

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Date of Submission01-Aug-1998
Date of Acceptance12-Jun-1999
 

How to cite this article:
Al Asseeri MO, Laajam MA, Mofti AB, Jamal AA. Massive melena from a dieulafoy's type ulcer of the jejunum: A case report. Saudi J Gastroenterol 2000;6:56-8

How to cite this URL:
Al Asseeri MO, Laajam MA, Mofti AB, Jamal AA. Massive melena from a dieulafoy's type ulcer of the jejunum: A case report. Saudi J Gastroenterol [serial online] 2000 [cited 2022 Jan 27];6:56-8. Available from: https://www.saudijgastro.com/text.asp?2000/6/1/56/33507


Dieulafoy's ulcer or caliber persistent artery or cirsoid aneurysm is a very rare cause of lower gastrointestinal tract haemorrhage, being mainly described in the stomach. It has characteristic features that distinguish it from other more common vascular malformations of the gastrointestinal tract (GIT). More recently, lesions of colon have been described. Dieulafoy ulcer of the small intestine is even a scarely found. We report a case of a life­threatening melena in which the source of bleeding could only be identified intraoperatively from such a lesion in the jejunum. The diagnostic dilemma and role of surgical exploration is discussed.


   Case history Top


A 64-year-old Saudi male known hypertensive on irregular treatment presented to the emergency department with a two weeks history of epigastric discomfort, dizziness, fatigue and melena. Apart from tachycardia, he was normotensive, looked well and oriented. Rectal examination and proctoscopy revealed no anal lesions but few blood clots. The haemoglobin level was 12.6gm/dl. The patient was admitted for observation and further assessment. Esophago-gastroduodenoscopy was normal and colonoscopy showed only few red clots without any obvious sites of bleeding. Tow days later the patient had another episode of melena and the haemoglobin dropped to 9.2gm/dl, thus he received two units of packed red blood cells. Meckel's nuclear scan performed on emergency basis was negative. The patient condition stabilized and was discharged on the tenth day of his admission. However, two days later, he presented to our emergency department in a state of shock after passing two bouts of black stool with fresh blood. His blood pressure was 90/50mmHg and the pulse rate reached 130/min. He was pale, semi-conscious with signs of hypovolaemic shock. The haemoglobin level was 6.0gm/dl. The patient was resuscitated with fluids and blood transfusion. Due to unavailability of selective mesenteric artery angiography at that time, emergency labeled red blood cell nuclear scan was performed and showed increasing activity in the region of the caecum and ascending colon. Two days later, the patient passed a motion of red blood clots and large amount bright red blood and went into state of shock. After successful resuscitative measures emergency surgical exploration was performed. On table colonoscopy guided through the opened abdomen revealed multiple large clots filling the caecum and proximal ascending colon. Right haemicolectomy was performed and while restoring the continuity of the bowel, the distal ileum was found to be distended with blood. The proximal bowel clamp was removed and the ileum was decompressed by suction. The aspirate was fresh blood. The whole small bowel was examined carefully by stripping palpation and transillumination. This revealed a small intraluminal blackish spot on the mesenteric side 30cm from the ligament of Treitz. Isolation of this segment of jejunum between clamps showed the segment to be filled and distended quickly with blood. There was a well developed feeding vessel traversing the mesentery into the lesion. A ten centimeter segment of the jejunum containing the lesion was excised and the bowel continuity was restored in the usual manner and the abdomen was closed. The patient received a total of, 14 units of blood transfusion during the period of resuscitation and exploration of the abdomen. Histopathologic examination showed small mucosal erosion extending to muscularis mucosa with direct exposure of a wide artery lying in the submucosa consistent with the diagnosis of Dieulafoy's ulcer of the jejunum [Figure - 1], [Figure - 2], [Figure - 3]. The post-operative course was uneventful and the patient was discharged in stable condition on the seventh post-operative day. The patient remained well without further episodes of melena. when seen six months later.


   Discussion Top


Gastrointestinal tract bleeding is a common surgical problem and the identification of the site of bleeding can be as distressing to the surgeon as it is to the patient despite the availability of several highly sophisticated imaging and endoscopic techniques. Preoperative precise determination of the site of bleeding can be impossible especially when the source of haemorrhage occurs anywhere beyond the ligament of Treitz. Hence, laparotomy and careful examination of bowel by palpation and inspection may be the only sure technique to localize the site of bleeding. This was the case in our patient where the dilemma could only be dealt with successfully at laparotomy. The right colon was unnecessarily resected before examining the bowel carefully to locate the site of bleeding, highlighting the non-specificity of the nuclear scans in localizing the site of bleeding in such cases. The role of endoscopy in cases of upper gastrointestinal bleeding is well known especially in gastric lesions. Dieulafoy lesions are commonly found in the lesser curvature. Such lesions may be ameanable for endoscopic therapy, which should be attempted as a primary treatment[3]. There are several reports demonstrating the role of endoscopy for diagnosis and treatment of Dieulafoy's lesion especially gastric lesions. Several reports highlight the value of angiography in localization and management of the bleeding sites along the GIT[4],[6]. This could not be performed in this patient due to a technical fault.

Endoscopy the small bowel and localizing the site of bleeding is a very sophisticated and new tool of diagnosing lesions distal to the ligament of Treitz intra-operatively by a small antrotomy opening but its value is not well documented yet due to its limited availability. However, it will definitely add more to our success in managing majority of cases of small bowel lesions.

Gallard was the first to describe massive gastrointestinal bleeding secondary to a dilated submucosal vessel in the stomach[9],[10]. In 1898, Dieulafoy reported three cases of gastric haemorrhage with same type lesion, hence the disease became known as "exulceratio simplex Dieulafoy" in Europe while in United States, it has been known as "gastric aneurysm", "submucosal arterial malformation" or "cirsoid aneurysm"[11],[12],[13],[14],[15].

These lesions were all initially described in the stomach but since the seventies, similar lesions in other parts of the gastrointestinal tract, mostly in the jejunum [7],[8],[16],[17] but also in the colon[18] and the rectum[19] have been reported. Our case shares several features in the clinical presentation, diagnosis and management as those reported earlier by Levine and Valk in 1944 and more recently by Vetto in 1989[7],[8].

We believe that this is the first case of a Dieulafoy's type ulcer of the jejunum to be reported in the Middle East and conclude that such lesions are not rare but are rather overlooked or unrecognized due to the difficulties in localizing them. The condition is potentially life threatening and could be lethal. Intraoperative endoscopy of the small bowel beyond the ligament of Treitz with careful and repeated palpation and inspection of the small bowel under close and controlled transillumination may be considered as the technique of choice to identify such lesions and improving the prognosis.

 
   References Top

1.Bedford RA, Van Stolk R, Sivak MV Jr, Chung RS, Van Dam J. Gastric perforation after endoscopic treatment of a Dieulafoy's lesion. Am J Gastroentrol 1992;87:2447.  Back to cited text no. 1    
2.Jaspersen D. Dieulafoy's disease controlled by Doppler ultrasound endoscopic treatment. Gut 1993;34:857-8.  Back to cited text no. 2    
3.Grisendi A et al. Combined endoscopic and surgical management of Dieulafoy vascular malformation. J Am Coll Surg 1994;179:182-6.  Back to cited text no. 3    
4.Hoffman J, Beck H, Jensen HE. Dieulafoy's lesion. Surg Gyn Obst 1984;159:537-40.  Back to cited text no. 4    
5.Helliwell M, Irving JD. Haemorrhage from gastric artery aneurysms. Br Med J 1981;282:460-1.  Back to cited text no. 5    
6.Gough MH. Submucosal arterial malformation of the stomach as the probable cause of recurrent severe haematemesis in a 16 year old girl. Br J Surg 1977;64:522-4.  Back to cited text no. 6    
7.Levine J, Valk AD. Aneurysm with rupture of a submucosal artery in the jejunum. Am J Clin Pathol. 1944;14:586-9.  Back to cited text no. 7    
8.Vetto JT, Richman PS, Kariger K, Passaro E. Cirsoid aneurysms of the jejunum. Arch Surg. 1989;124:1460-2.  Back to cited text no. 8    
9.Gallard T. Aneurysms milires de L 'estomos: Societe Medicale des Hospitalux. Bull Soc Med Hosp Paris 1884;1:84-91.  Back to cited text no. 9    
10.Dieulafoy G. Exulceratio Simplex. L'intervention chirurgicale dans les hematemeses foudroyantes consecutives a 1'exulceration simple de l'estomac. Bull Acad Me 1898;49:84.  Back to cited text no. 10    
11.Chapman I, Lapi N. A rare cause of gastric haemorrhage. Arch Intern Med. 1963;112:101-5.  Back to cited text no. 11    
12.Goldman RL. Submucosal arterial malformation ('aneurysm') of the stomach with fatal haemorrhage. Gastroenterol 1964;46:589-94.  Back to cited text no. 12    
13.Palmer ED, Boyle HW. Sclerotic submucosal gastric artery:A cause of haemorrhage. Am Surg.1964,30:83-7.  Back to cited text no. 13    
14.Richter RM. Massive gastric haemorrhage from submucosal arterial malformation. Am J Gastroenterol. 1975;64:324-6.  Back to cited text no. 14    
15.Finkel LJ, Schwartz IS. Fatal haemorrhage from a gastric cirsoid aneurysm. Hum Pathol. 1985; 16:422-4.  Back to cited text no. 15    
16.Rathmell TK, Hotwell RJ, Greeley JP. Congenital aneurysm of the jejunum producing total intestinal haemorrhage. Arch Pathol. 1951;51:461-5.  Back to cited text no. 16    
17.Matuchansky C, Bubin P, Abadie JC, Payen J, Gasquet C, Barbier J. Jejunal bleeding from a solitary large submucusal artery. Gastroenterol 1978;75:110-13.  Back to cited text no. 17    
18.Richard WO, Grove-Mahoney D, Williams LF. Haemorrhage from a Dieulafoy type ulcer of the colon:A new cause of lower gastrointestinal bleeding. American Surgeon 1988;54:121-4.  Back to cited text no. 18    
19.Franko E, Chardavoyne R, Wise L. Massive rectal bleeding from a Dieulafoy's type of ulcer of the rectum:A review of this unusual disease. AM J Gastroenterol 1991;86:1545-7.  Back to cited text no. 19    

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Correspondence Address:
Mohammed O Al Asseeri
Department of Surgery, Security Forces Hospital, P.O. Box 3643, Riyadh 11481
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864731

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