S4633 Bleeding Beyond Reach: A Jejunal Dieulafoy’s Lesion Requiring Advanced Endoscopic Rescue

Introduction: Dieulafoy's lesion (DL) is a rare but potentially life-threatening cause of gastrointestinal bleeding (GIB), accounting for less than 2% of cases. While commonly localized in the proximal stomach, jejunal DLs are quire rare, and a diagnostic challenge given their location and intermittent bleeding. We report a case of jejunal DL successfully managed with advanced endoscopic therapy. Case Description/Methods: A 39-year-old man with no significant medical history presented with sudden epigastric pain, melena and dark emesis. He denied any medication use except nonsteroidal anti-inflammatory drugs taken 4 days prior. Computed tomography abdomen/pelvis and computed tomography angiography showed no active bleeding. Admission hemoglobin was 10.8 g/dL but declined to 7 g/dL with tachycardia and hypotension. He was admitted to the intensive care unit and received 9 units of packed red blood cells under massive transfusion protocol. Esophagogastroduodenoscopy showed fresh blood in the duodenum but no source. Push enteroscopy using a pediatric colonoscope revealed a 3 mm spurting lesion with a visible vessel in the jejunum, consistent with DL. Hemostasis was achieved using 6 hemoclips, epinephrine injections, bipolar cautery and hemospray. No further bleeding was observed on repeat endoscopy and imaging, interventional radiology deferred embolization due to ischemic risk. The patient's hemoglobin stabilized without further transfusion. He resumed oral intake and was discharged on high-dose pantoprazole with taper and sucralfate. Discussion: DL accounts for 1% to 2% of acute GIB mostly in the stomach (72%), duodenum (15%), esophagus (8%), but rarely in jejunum. Diagnosis requires high clinical suspicion and specialized endoscopy. A 2022 systematic review reported 98 small bowel DL since 1978; 48% jejunal with a mean age of 45.5 and male predominance (62.5%), aligning with our case. Jejunal DLs often elude standard imaging. Push enteroscopy using a pediatric colonoscope, which allows reaching 45–60 cm past the ligament of Treitz, was key for localization in this case. While mechanical therapies are effective, combination endoscopic therapy yields better results. Multimodal treatment (Clips, epinephrine, cautery and hemospray) achieved hemostasis in this case. Rebleeding after embolization is higher for small bowel lesions due to limited collaterals and extensive vascular territory. The decision to forego interventional radiology highlights the efficacy and safety of endoscopic therapy when expertly applied for obscure GIB. this case contributes to the limited literature on jejunal DLs.