Phenylephrine-provoked endoscopy reveals an occult Dieulafoy’s lesion in a duodenal diverticulum: A case report and review of literature

Figure 1 Enhanced abdominal computed tomography imaging. A: Non-contrast computed tomography scan showing multiple duodenal diverticula; B: Arterial phase contrast imaging revealing a suspected arterial vessel coursing through the wall of one diverticulum. Blue arrow: Duodenal diverticula in the horizontal segment of the duodenum; yellow arrow: Suspected intradiverticular arterial vessel.

Figure 2 Endoscopic identification and management of a Dieulafoy’s lesion in a duodenal diverticulum under phenylephrine provocation. A: Active bleeding from the lesion occurs after blood pressure provocation with phenylephrine; B: Colonoscopic view shows a 1-2 mm erythematous spot (white arrow) on the anterior wall of a duodenal diverticulum adjacent to the duodenal papilla; C: Complete haemostasis is achieved by submucosal epinephrine injection followed by placement of three haemostatic clips.

Figure 3 Flowchart of vasopressor-based provocative endoscopy for obscure gastrointestinal bleeding. Ovals: Start/end; Rectangles: Patient selection/contraindications; Diamond: Provocative endoscopy/alternative treatments; Circles: Supportive/safety conditions; GIB: Gastrointestinal bleeding; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; HR: Heart rate.