While gastric Dieulafoy's lesions are well known, there was little experience about the Dieulafoy lesions located at small bowel. In the gastric lesion, endoscopic treatment is regarded as a initial therapy of choice. For the duodenal lesion, albeit in a small cases, endoscopic treatment largely replaced the need of surgery[5]. This fact, combined with the advent of the effective endoscopic hemostatic methods, could explained the difficulty to obtain a surgical specimen for definitive pathologic diagnosis. Therefore, some authors suggest the Dieulafoy-like lesion is a more accurate description when only endoscopic observation is available. Furthermore, repeated endoscopic examination is frequently necessary because the bleeding point can be so small that unless there was a ongoing bleeding, it may be difficult to detect the lesion.
In our case, the lesion appeared as a active arterial spurting of blood without accompanying ulceration and through normal surrounding mucosa. This fulfills the commonly agreed endoscopic criteria for the diagnosis of Dieulafoy lesion. Forward viewing conventional endoscopy fails to locate the lesion because the lesion is at the perimapullary area. The precise location of the lesion was a inlet of the periampullary diverticulum about 2 cm from the ampullar opening.
Duodenal diverticulum are found mostly from the concave aspect of the duodenum. In one study, 62% were in the second part and 30% in the third part and 8% in fourth part of the duodenum[6]. They are mostly asymptomatic, but bleeding, inflammation and perforation are the rare complication. Periampullary diverticulum refers to the diverticula within 2.5 cm of the ampulla of Vater. Although periampullary diverticula are rarely symptomatic, their association with gallstones and pancreatitis is well documented[7].
Actual bleeding site in our case can not be attributed solely to the diverticular bleeding. In a diverticular bleeding, usual bleeding site is in the dome of diverticulum where aberrant blood vessels lay over the thin walled luminal surface[4, 8]. We observe the bleeding spot at the marginal surface of the diverticular inlet. Hence, It is reasonable to think that actual bleeding is from the Dieulafoy-like lesion at the brim of diverticulm. But it is still possible that this lesion is in fact due to the development of a Dieulafoy-like lesion as a result of a mechanical or other stresses to the mucosal or submucosal vessels at the mouth of the diverticulum. Recent use of non-steroidal anti-inflammatory drugs can also be regarded as a contributing factor in our case.
There were many endoscopic therapeutic options for the Dieulafoy bleeding. Endoscopic therapy have been very useful for the treatment of Dieulafoy lesions, especially when they were detected and able to be reached by endoscope. Endoscopic therapy includes epinephrine includes monotherapy (epinephrine, sclerosant, alcohol, thermal probe) [9–11] or combination therapy(injection followed by thermal probe coagulation)[2, 12] or mechanical hemostasis methods(band ligation, hemoclip)[13, 14].
There was report about the successful hemochip placement at the Dieulafoy-like lesion in a duodenal diverticulum through a forward-viewing endoscope[15]. But, conventional forward-viewing endoscope could not yield a correct diagnosis particularily due to the difficult location of the lesion. The medial and marginal portion of duodenal diverticulum can only be inspected by the side-viewing endoscope. Any maneuvers using the catheter through a side-viewing endoscope were considered difficult because of acute angulation at the tip of the scope. After hemostasis was not achieved by epinephrine injection, we could not consider any endoscopic therapeutic options other than angiographic intervention, because rather limited view of field and motion ability of the side-viewing endoscope hinder any further therapeutic maneuvers. But when the rebleeding occurred, after a failure of angiographic embolization, We tried the mechanical hemostasis methods by using metal hemoclips. Though it was difficult to locate and release the hemoclips at the time, immediate hemostasis achieved instantly after hemoclip application. Thus the patient recovered uneventfully without rebleeding while avoiding surgery that could cause unpredictable morbidities.