S4660 Dieulafoy Lesion: A Rare Cause of Postpartum Bleeding

Introduction: Upper gastrointestinal bleeding (GIB) originates above the ligament of Treitz and is commonly caused by ulcerative and erosive lesions or less commonly due to vascular lesions or masses. While most upper GIBs can be identified via endoscopy, the source of bleeding remains unidentified in 10–15% of cases. A Dieulafoy lesion (DL) is a vascular malformation of the gastrointestinal tract that accounts for 1%-2% of all GIB. DLs are typically asymptomatic, but can cause intermittent bleeding or massive hemorrhage. This case presents a 25-year-old woman with unstable hemoglobin levels following a cesarean section (CS) delivery, subsequently found to be massive blood loss secondary to DL. Case Description/Methods: A 25-year-old woman with a history of gastroesophageal reflux disease and prior CS presented to obstetric triage at 35 weeks gestation with contractions. The evening following expedited CS, she developed acute onset abdominal pain and was found to have reduced hemoglobin levels (8.8 g/dL compared to 9.9 g/dL at admission). Computed tomography angiography showed hemo-pneumoperitoneum secondary to a left uterine artery bleed that required laparoscopic intervention with successful ligation. The following day, she was noted to have a 3 g/dL drop in hemoglobin. Repeat CTA showed new free fluid in the stomach lumen. An urgent bedside esophagogastroduodenoscopy demonstrated a bleeding DL. There was stigmata of recent bleeding on the lesser curvature of the stomach and a few non-bleeding duodenal ulcers without stigmata of bleeding. Temporary hemostasis was achieved using 2 hemostasis clips and EndoClot® Submucosal Injection Solution with complete hemostasis using coil embolization. The patient was discharged after hemoglobin stabilization. Discussion: DL is an infrequent, but potentially life threatening source of upper GIB. There is continuous debate regarding the origin of DL bleeding. Studies have suggested a link between DL bleeds and chronic utilization of anticoagulants and nonsteroidal anti-inflammatory drugs. Given the rarity of DL in a patient of this age, it must be considered if physiologic adaptations such as expanded blood volume and hormonal shifts in gestation may serve as triggers. In addition to endoscopic clipping, coil embolization may be recommended for refractory bleeding. Overall, this report underscores the need to consider this rare, yet dangerous cause of GIB in obstetrics patients.