A gastric dieulafoy lesion presenting with life-threatening upper gastrointestinal hemorrhage during recovery from hypertriglyceridemic acute pancreatitis: a case report.

BACKGROUND

Dieulafoy lesions are an uncommon but potentially life-threatening cause of non-variceal upper gastrointestinal bleeding, caused by rupture of a large-caliber submucosal artery through a minute mucosal defect; diagnosis is difficult because bleeding is intermittent and the surrounding mucosa appears nearly normal. Hemorrhage from a gastric Dieulafoy lesion during recovery from hypertriglyceridemic acute pancreatitis (HTG-AP) has rarely been reported.

CASE PRESENTATION: A man in his twenties with severe obesity presented with acute epigastric pain after alcohol and a high-fat meal. Serum triglycerides were 53.67 mmol/L (reference 0.56-1.70), and CT confirmed acute pancreatitis. Because of extreme hypertriglyceridemia and evolving organ dysfunction, he received intensive lipid-lowering therapy, plasma exchange, continuous renal replacement therapy, and supportive care in the ICU, and improved. During recovery he developed sudden massive hematemesis with tachycardia, hypotension, and a fall in hemoglobin to 65.9 g/L. Emergency endoscopy showed extensive intragastric clots and could not locate the source. After stabilization, repeat endoscopy revealed an isolated thrombus-like protrusion with active oozing on the lesser curvature near the cardia, with otherwise normal mucosa, consistent with a Dieulafoy lesion; three metallic clips achieved immediate hemostasis. Contrast-enhanced CT excluded pseudoaneurysm, splenic-vein thrombosis, gastric varices, and other pancreatitis-related vascular complications. No recurrence occurred during hospitalization or approximately seven months of follow-up, with healed mucosa on later endoscopy.

CONCLUSION

A gastric Dieulafoy lesion is a rare but life-threatening cause of bleeding during recovery from HTG-AP. A nondiagnostic first endoscopy because of clot retention does not exclude it, and persistent bleeding warrants repeat endoscopy after stabilization and gastric clearance. Bleeding should not be attributed solely to stress injury or anticoagulation; an underlying structural lesion should be sought. Clipping achieved durable hemostasis in this patient, but a single case cannot establish comparative efficacy.