Surgery for a gastric Dieulafoy’s lesion reveals an occult bleeding jejunal diverticulum. A case report

Jejunal diverticulosis (JD) is an uncommon disease and usually asymptomatic [1] with an incidence of 0.06–1.3% although the prevalence seems to increase with age. The highest incidence of JD occurs during the sixth and seventh decades of life, and the disease is thought to be more common in males. It is frequently seen in the duodenum while jejunal and ileal locations are very rare. More commonly JD is diagnosed as an incidental finding of computed tomography imaging, small bowel barium radiographic series, or during surgery [2, 3].

This report presents a case of small bowel bleeding jejunal diverticulum with enteroliths formed inside casually discovered intraoperatively as another cause of bleeding in a patient with a Dieulafoy’s lesion.

A 75-years-old-man was admitted for an undiagnosed gastric bleeding lesion treated with endoscopic clips. He suffered of anemia and asthenia without nausea, abdominal pain or weight loss. Laboratory studies revealed mild anemia with hemoglobin level of 10 g/dL. An upper gastrointestinal endoscopy was performed showing a 2 cm bleeding ulceration at the corpo-antral junction in the greater curve. Endoscopic ultrasound (EUS) confirmed the presence of a single long vessel of 1 mm diameter perforating the muscular layer of the gastric wall and coming to lie in the submucosa. The arterial nature of the vessel was confirmed by pulse Doppler [4, 5]. It was diagnosed a Dieulafoy’s lesion (DL) according to the following diagnostic criteria: 1. active arterial spurting or micropulsatile bleeding from a minute mucosal defect less than 3 mm or normal mucosa; 2. visualization of a protruding vessel with or without bleeding within a small mucosal defect or normal mucosa; 3. appearance of a fresh, adherent clot to a minute mucosal defect or normal mucosa [6]. The first choice was endoscopic treatment. Injection of epinephrine (1:10) and the use of endoscopic clips led to complete cessation of bleeding [7]. No complications developed after the procedure and there was no recurrence of bleeding at the 90-day follow-up. After six months the patient was readmitted because of a worsening of general condition with acute upper GI bleeding. An endoscopic treatment was performed placing three clips. At the follow-up the failure of procedure needed a gastric wedge resection.

The patient suffered of a severe stage of COPD and laparoscopic procedure was contraindicated so the laparotomy was performed. Intraoperative abdominal exploration incidentally revealed a jejunal diverticulum close to caecum [Fig.1]. An ileocecal resection was performed with a double-layer side-to-side single stitches anastomosis (Vicryl*Plus 3/0SHplus). Afterwards, a gastric wedge resection was performed by a linear stapler (Covidien DST Series™ GIA™ 60-3.5) [Fig.2].

The discharge was in the 5^th day post op.

Macroscopic examination showed a segment of intestine approximately 30 cm in length with JD on the antimesenteric side. Three enteroliths were founded formed inside with a smooth dark outer surface, the largest one of 3 cm in major diameter without protruding into the intestinal lumen. Histological sections of bowel showed wall thinning of the jejunal mucosal with bleeding areas and intense neutrophilic exudate that covered all the coats of the intestinal wall. The gastric gross examination confirmed a Dieulafoy’s lesion.

One year after surgery the patient has a hemoglobin level of 14,5 g/dL.

This case report shows in the same patient two rare causes of GI bleeding and permits a discussion about their suitable treatment.

In conclusion, these conditions, although rare, can be multiple and result in potentially life-threatening bleeding. The clinician must be mindful to the possibility of multisite lesions and to the correlation between results of the investigations and clinical condition of the bleeding patient. In this case the incidental discovery of an occult bleeding lesion and a targeted surgical approach made us to ensure a suitable therapy of GI bleeding. The follow up will be done by capsule endoscopy, a safe and effective method of intestinal post operative control [17].