The enigmatic bleed

The field of endoscopy is a challenging and rewarding field. In nearly forty years of experience, Dr VGM has dealt with various emergency procedures and emerged successful. Here was one elusive challenge.

This 45 year old gentleman, used to present with recurrent bleeding and passing blood in motion (black motion). (At this point, its important to note that bleeding in the stomach or intestine can present as black motion.) He had undergone several endoscopies in several hospitals and found no solution. He was transfused blood many times during each episode of bleeding. He would recover and go back to work only to get admitted again after 4 months.
We evaluated him with a repeat endoscopy which showed fresh blood in the intestine. We searched and searched for the possible source, but could not find it. We tried to see using side viewing endoscope (a special endoscope to see the bile duct orifice). By the time we had exchanged the scope, the bleeding had stopped and surprisingly there was no blood in the intestine again.
We proceeded to do CT visceral angiography during an episode of bleeding, but found no active bleeding. This entity can detect bleeding only if there is ongoing significant bleeding. Then we proceeded with capsule endoscopy, which showed the entire length of the gut from the mouth to anus, and alas... found no bleeding. He was completely clean.

Similar to previous episodes, he improved, was discharged and went back to work. And we were left racking our brain for the source of bleeding. Now, we were sure of one thing- the bleeding lesion, whatever it was, disappeared after bleeding, leaving a clean intestine.
So as per our request, the patient came back to us for the second time with a massive bleeding episode. Now we went back to see the intestine (duodenum, the first part of the intestine). And this is the video of what we saw. The lesion was spurting blood like an open hose. Immediately we applied hemoclips and sealed off the bleeding. Finally we diagnosed the cause of the bleeding and also stopped the bleeding. We diagnosed a rare (though not unheard of) condition called Dieulafoy’s lesion. These lesions can be seen in stomach or intestine, and is due to tortuousity of the vessels. They can bleed profusely and then close up entirely and then cannot be spotted.
For safety we injected a tattoo dye near the site of the bleeding spot, in case we needed to locate the spot again. Because of the tattoo dye, now the lesion can be spotted endoscopically and laparoscopically in case of any recurrent problem in future.

It was very gratifying professionally to be able to solve the problem for the patient. The patient had been saved from a financial and emotional burden. But above and beyond that… to Dr VGM, the gastro doctors and the endoscopy team… it was an unforgettable moment.. to be shared with you all…

Dr.Madhura Prasad Suman
MD, MRCP (UK), FTE (Endo), DNB (med. gastro)
Consultant Medical Gastroenterologist

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