Jejunal Dieulafoy's lesion - An exceptionally rare and challenging culprit of gastrointestinal bleeding

A 78-year-old male presented to the emergency department with melena. He was hemodynamically stable but displayed a hemoglobin level of 5.8g/dL necessitating blood transfusion. Initial esophagogastroduodenoscopy and colonoscopy failed to identify a bleeding source, prompting a capsule endoscopy that revealed an active bleeding site in the jejunum. A single-balloon enteroscopy identified an aberrant vessel in the mid-jejunum protruding through a 3mm mucosal defect, devoid of surrounding inflammation, consistent with a Dieulafoy's lesion, in which two through-the-scope clips were applied. Despite this, ongoing melena and decreasing hemoglobin levels in the subsequent days led to a second single-balloon enteroscopy, which confirmed continued bleeding. Definitive hemostasis was achieved through diluted adrenaline injection, four additional through-the-scope clips, and polidocanol sclerotherapy. Jejunal Dieulafoy's lesion is extremely rare and presents notable diagnostic and therapeutic challenges. Ávila et al. recently reported a case where, despite capsule endoscopy identifying the bleeding site, single-balloon enteroscopy failed to confirm the diagnosis, leading to the use of motorized enteroscopy with argon and metallic clip treatment. Similarly, our experience highlights the diagnostic value of capsule endoscopy and the crucial role of device-assisted enteroscopy in a multimodal therapeutic approach, which was essential for achieving successful hemostasis.