Dieulafoy's Lesion of the Major Duodenal Papilla Presenting as Obscure Upper Gastrointestinal Bleeding: A Case Report.

Dieulafoy's lesion is an uncommon vascular anomaly that can cause life-threatening gastrointestinal bleeding. While the stomach is the most frequently affected site, involvement of the major duodenal papilla is exceedingly rare and may escape detection with conventional forward-viewing endoscopy. We report a rare case of papillary Dieulafoy's lesion presenting as obscure upper gastrointestinal bleeding in a patient receiving rivaroxaban. A 69-year-old woman with deep vein thrombosis receiving rivaroxaban, hypertension, and hypothyroidism presented with recurrent melena and severe anemia (hemoglobin 5.8-7.1 g/dL). Despite extensive evaluation, including capsule endoscopy, colonoscopy, and two forward-viewing esophagogastroduodenoscopies, no bleeding source was identified. Persistent anemia and fresh blood in the second portion of the duodenum raised suspicion of a periampullary bleeding source. Side-viewing duodenoscopy subsequently identified a 1 × 1 mm erythematous lesion with active bleeding at the major duodenal papilla, consistent with a Dieulafoy's lesion. Combination endoscopic therapy with epinephrine injection, bipolar thermal coagulation, and hemoclip placement achieved complete hemostasis. Rivaroxaban was temporarily discontinued, and no recurrent bleeding or post-procedural pancreatitis occurred during 6 months of follow-up. This case highlights the diagnostic challenge of papillary Dieulafoy's lesions when conventional forward-viewing endoscopy is non-diagnostic. Early side-viewing duodenoscopy is essential when a periampullary bleeding source is suspected, and combination endoscopic therapy can provide durable hemostasis, even in anticoagulated patients.