A rare cause of massive upper gastrointestinal bleeding in a dialysis patient: synchronous Dieulafoy lesions.

Case

A 78-year-old man on haemodialysis for 6 years presented with a 1-day history of haematemesis and melaena. His past medical history includes chronic pyelonephritis, gastric ulceration on the greater curvature of the stomach (2008) and hypertension. There was no history of excess alcohol intake or non-steroidal anti-inflammatory use. He was fluid-resuscitated and underwent an emergency oesophagogastroduodenoscopy (OGD) which demonstrated blood in the stomach but no bleeding source. He had a further drop in haemoglobin 24 h later, and repeat OGD was unremarkable. He went on to have a CT angiogram with a view to embolization, which failed to identify a bleeding vessel. Surgical review excluded the possibility for surgical intervention due to lack of an identifiable lesion.

The patient was discharged home after several days of observation but presented 12 h later with recurrent haematemesis. Emergency endoscopy with pre-procedure prokinetics demonstrated a Dieulafoy lesion in the cardia (see Figure 1) which was successfully treated with endoclips and adrenaline injection. He had a further haematemesis 36 h later with repeat endoscopy demonstrating another Dieulafoy lesion in the anterior wall of the fundus which was treated as before (see Figure 2).

Fig. 1

Dieulafoy lesion in the cardia.

Fig. 2

Dieulafoy lesion in the fundus.

Discussion

Dieulafoy lesions are submucosal tortuous arterioles that bleed through a small punctate erosion in an otherwise normal mucosa. Only 5.8% of upper gastrointestinal (GI) bleeds are due to these lesions [1] and are typically found in the lesser curvature of the stomach [2]. Chronic kidney disease is a common risk factor; however, there are very few reported cases of Dieulafoy lesions in dialysis patients [3]. This case demonstrates the difficulties in the diagnosis of Dieulafoy lesions for which repeated endoscopies were required. Also, Dieulafoy lesions can occur synchronously, as in this case, and a careful search for multiple lesions is necessary to avoid further bleeding.

Conflict of interest statement. None declared.