S4641 Presumed Dieulafoy, Proven Hemangioma: A Rare Cause of Refractory Small Bowel Bleeding Requiring Surgical Resection

Introduction: Dieulafoy lesions are rare vascular malformations that account for 1 to 2 percent of gastrointestinal bleeds and up to 6.5 percent of non-variceal upper gastrointestinal hemorrhages. They are composed of large-caliber submucosal arteries that erode through the mucosa, resulting in acute and often massive bleeding. Endoscopic therapies such as clipping, band ligation, or thermal coagulation are typically effective, with surgery required in fewer than 6 percent of cases. In patients with recurrent bleeding despite appropriate endoscopic treatment, other vascular causes such as submucosal hemangiomas should be considered. Case Description/Methods: A 62-year-old man with metastatic bladder cancer, chronic kidney disease, and a right lower extremity deep vein thrombosis diagnosed on December 14, 2024 (started on apixaban), presented on December 19, 2024, with melena, fatigue, and transfusion-dependent anemia. He received 7 units of packed red blood cells over multiple admissions. Anticoagulation was held and an inferior vena cava filter was placed. Esophagogastroduodenoscopy revealed no overt source of bleeding and colonoscopy showed hematin in the terminal ileum. Capsule endoscopy demonstrated active bleeding at approximately 50% of the small bowel transit time, suggesting a jejunal or proximal ileal source. Double balloon enteroscopy (DBE) identified a presumed Dieulafoy lesion in the proximal ileum, managed with epinephrine injection, hemostatic clips, and tattooing. The patient was readmitted with recurrent melena. Repeat DBE failed due to looping. Computed tomography angiography and formal angiography were non-diagnostic. Laparoscopic-assisted intraoperative enteroscopy revealed active bleeding 5 centimeters distal to the tattooed site. A 20 cm segment of proximal ileum was resected. Final pathology confirmed a cavernous submucosal hemangioma. Discussion: Small bowel hemangiomas account for approximately 10 percent of benign small bowel tumors and are most commonly found in the jejunum or ileum. They appear submucosally as soft, violaceous lesions and are often missed on capsule endoscopy or imaging. Surgical resection is typically required. This case highlights the importance of maintaining a broad differential in obscure gastrointestinal bleeding and emphasizes the value of tattooing in accurately localizing lesions for targeted surgical treatment.