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Keywords
Dieulafoy lesion, post-partum, video capsule endoscopy
Disclaimer: consent was obtained for all procedures, and no experimental methods were employed.
Abstract
A 32 yr old woman presented in the postpartum period with gastrointestinal hemorrhage. Routine endoscopies were non-diagnostic. The patient was ultimately found to have a jejunal Dieulafoy lesion using capsule endoscopy. Surgical management resulted in curative resection of the lesion.
Case
A 32-year-old female presented to the emergency department after fainting. She had been passing tarry, maroon stool for the 24 hours prior to arrival at the hospital and had blacked out trying to get out of bed.
She was 3 weeks post-partum following an uncomplicated pregnancy with vaginal delivery. Her hemoglobin was 12.4 after delivery and was 7.7 at presentation to the emergency department. She had been taking Ibuprofen for a few days after her pregnancy, otherwise she took no medications except pantoprazole for dyspepsia. She had no history of GI bleeding, no vaginal bleeding and no abdominal pain.
Her past medical history and family history was unremarkable.
She did not use tobacco or alcohol.
Her physical examination revealed a comfortable cooperative patient who appears her stated age. Her pulse on presentation was 150 and her systolic blood pressure was 100. Her abdominal exam was unremarkable, and maroon stool was present on rectal exam.
Her INR was 1.2, her platelet count was 295 x10^9, her MVC was 92 and her hemoglobin was 7.7.
The patient was given fluids intravenously, transfused and underwent upper and lower endoscopies. The endoscopies were normal other than blood in the colon. The ileum was without lesions. A capsule endoscopy was performed which revealed an active bleeding site in the mid jejunum based on time from the pylorus and the capsule localizer (Video1). Figure 1 shows a selected image from the capsule endoscopy in which the bleeding site is clearly visible. Figure 2 shows the approximate region of the bleeding site based on the capsule localizer.
The patient underwent surgical exploration on the basis of the capsule endoscopy. A midline incision was made curving to the left of the umbilicus. There was no free fluid in the peritoneal cavity. The small bowel was palpated from ligament of Treitz down to the cecum. In the mid jejunum a nodular lesion was found on the antimesenteric border which coincided with the upper point of where there was blood in the small bowel. The small bowel mesentery to this
intervening segment was divided and the segment of bowel was removed.
Histology revealed a Dieulafoy lesion Figure 3 .
The patient recovered uneventfully and had no evidence of problems at a 3 month evaluation by her obstetrician.
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Figure 1 |
Figure 2 |
Figure 3 |
Discussion
Dieulafoy lesions are submucosal arterioles which can rupture and cause massive bleeding.1 These lesions usually become evident in older patients in which possible arteriolar damage leads to rupture and bleeding. The aberrant placement of the artery is thought to be congenital as suggested by the occasional finding of Dieulafoy lesions in young children.2 Dieulafoy can occur throughout the GI tract, and in other submucosal locations such as the bronchus.3-7
Our patient had an unusual presentation of small bowel Dieulafoy lesion leading to hemorrhage for which capsule endoscopy was required to identify a lesion. The availability of capsule endoscopy resulted in a diagnosis and surgery within 24 hours of admission.
Management of Dieulafoy lesions depends somewhat on the location of the bleeding site. Lesions within the reach of the endoscope can often be managed by clipping, banding cautery or injection therapy, although endoscopic therapy is not always successful. Surgical removal of the aberrant artery is definitive and curative.1, 8-11
It is tempting to speculate that the post partum state and the bleeding were related in our patient. Pregnancy is generally a hypercoagulable state.12 Circulating levels of certain clotting factors including factors VII, VIII, IX, X, XII and fibrinogen all increase during gestation and the condition reverses in the post partum period. Regardless, bleeding from this type of lesion is obviously uncommon in the post partum period. This patient may have had an additional hemostatic stress from her use of ibuprofen, although bleeding from Dieulafoy lesions does not appear to be related to nonsteroidal anti-inflammatory drug use.13
To our knowledge, Dieulafoy bleeding in the post partum period has not been previously reported.
In summary, we identified a bleeding jejunal Dieulafoy lesion in the jejunum of a 32 year old woman in the post partum period. Prompt use of capsule endoscopy led to curative surgery with minimal morbidity.
References
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