Shen YJ, Song JJ, Liu XQ, Hu FL. Phenylephrine-provoked endoscopy reveals an occult Dieulafoy’s lesion in a duodenal diverticulum: A case report and review of literature. World J Gastroenterol 2026; 32(44): 121710 [DOI: 10.3748/wjg.121710]
Corresponding Author of This Article
Feng-Ling Hu, Chief Physician, Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Shangcheng District, Hangzhou 310006, Zhejiang Province, China. 1509035@zju.edu.cn
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Gastroenterology & Hepatology
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case-report
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Shen YJ, Song JJ, Liu XQ, Hu FL. Phenylephrine-provoked endoscopy reveals an occult Dieulafoy’s lesion in a duodenal diverticulum: A case report and review of literature. World J Gastroenterol 2026; 32(44): 121710 [DOI: 10.3748/wjg.121710]
Yu-Jie Shen, Feng-Ling Hu, Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang Province, China
Jiao-Jiao Song, Endoscopy Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
Xiao-Qin Liu, Department of Gastroenterology, Jingning People’s Hospital, Lishui 323500, Zhejiang Province, China
Author contributions: Shen YJ contributed to drafting of manuscript; Song JJ and Liu XQ contributed to the literature review; Hu FL performed the endoscopic procedure and revised the manuscript; all authors approved the final version.
AI contribution statement: AI tools (DeepSeek, Doubao and Bimuyu) were used solely for linguistic refinement and formatting assistance. No AI tool was involved in the generation of research data, interpretation of results, or formulation of conclusions. All AI-generated outputs were critically reviewed and revised by the authors. The authors take full responsibility for all content presented in this article.
Supported by Zhejiang Provincial Natural Science Foundation of China, No. LQ22H030015.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: All authors declare no conflict of interest in publishing the manuscript.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: Feng-Ling Hu, Chief Physician, Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Shangcheng District, Hangzhou 310006, Zhejiang Province, China. 1509035@zju.edu.cn
Received: March 31, 2026 Revised: May 13, 2026 Accepted: June 11, 2026 Published online: November 28, 2026 Processing time: 183 Days and 15.3 Hours
Abstract
BACKGROUND
The diagnosis of a Dieulafoy’s lesion located within a duodenal diverticulum (DD) presents a significant challenge, particularly during nonbleeding intervals. Pharmacological provocation has been proposed for obscure gastrointestinal bleeding. However, experience with provocative endoscopy is largely confined to antithrombotic-based protocols, which are associated with a delayed and unpredictable bleeding onset. The use of vasopressors as pharmacological provocation agents for endoscopic localization has not been previously explored.
CASE SUMMARY
We report the case of a 53-year-old woman with recurrent obscure gastrointestinal bleeding and a haemoglobin level ranging from 50 g/L to 84 g/L. Enhanced abdominal computed tomography showed multiple duodenal diverticula (DDs) in the distal duodenum, with a prominent arterial vessel traversing the wall of one diverticulum. Multiple standard endoscopies revealed fresh clots in the DDs but no definitive bleeding source during nonbleeding intervals. With clinical suspicion of a vascular lesion in the DDs, we administered phenylephrine to induce controlled hypertension for provocative endoscopy, which led to active bleeding from the previously concealed lesion within minutes. Using a colonoscope to enhance distal duodenal visualization, we successfully achieved endoscopic localization and haemostasis in the distal duodenum. The provocation was effective, with no recurrent bleeding or adverse events during a 2-month follow-up.
CONCLUSION
Phenylephrine-provoked endoscopy assists in localizing quiescent occult Dieulafoy’s lesion in a distal duodenal diverticulum with a colonoscope.
Core Tip: Dieulafoy’s lesion inside a duodenal diverticulum is difficult to identify during quiescent phase. Conventional provocative protocols use antithrombotic agents, accompanied by delayed and unpredictable bleeding onset. This case confirms that phenylephrine provocation combined with colonoscopy enables accurate localization of occult Dieulafoy’s lesion in the distal duodenal diverticulum.
Citation: Shen YJ, Song JJ, Liu XQ, Hu FL. Phenylephrine-provoked endoscopy reveals an occult Dieulafoy’s lesion in a duodenal diverticulum: A case report and review of literature. World J Gastroenterol 2026; 32(44): 121710
Dieulafoy’s lesion (DL) is an uncommon cause of acute upper gastrointestinal bleeding (GIB). Pathologically, it appears as a focal mucosal defect covering an abnormally dilated and tortuous submucosal artery[1]. Although most commonly found in the proximal gastric fundus, DL can occasionally occur within a duodenal diverticulum (DD) and tends to cause recurrent, life-threatening haemorrhage[2]. Its diagnosis during the quiescent period remains difficult. When bleeding ceases due to transient hypotension or local clot formation, the high-pressure arterial stump retracts beneath the mucosa, leaving the lesion endoscopically undetectable or appearing only as a subtle mucosal erosion[3]. Such lesions are harder to identify within the anatomical constraints of a DD, owing to limited visualization and maneuverability.
Provocative methods have been used to induce haemorrhages deliberately, and then these can be located[4-7]. Most commonly, the above are used to administer antithrombotic agents, fibrinolytic drugs or vasoconstrictors during angiography or endoscopy. While a few provocative angiography cases have been reported in the past four decades[8], experience with provocative endoscopy is even scarcer. Only sporadic cases have been published so far, all of which adopted antithrombotic drugs[4,9-12]. A disadvantage of these antithrombotic drugs-based provocation is a delayed and unpredictable onset of bleeding[4]. Such latency complicates real-time monitoring and, for pressure-sensitive lesions like DL, enhances the bleeding risk once the perfusion pressure threshold is exceeded. Phenylephrine, a selective α1-adrenergic agonist, offers a physiology-guided alternative by transiently elevating systemic blood pressure to induce bleeding, a mechanism particularly suited to pressure-sensitive vascular lesions[13]. Despite this theoretical rationale, the use of vasopressor-assisted provocative endoscopy has not been previously reported. Herein, we present a case of recurrent GIB from a DL within a DD, in which provocative endoscopy with phenylephrine successfully localized the nonbleeding lesion, with enhanced duodenal visualization facilitated by a colonoscope.
CASE PRESENTATION
Chief complaints
A 53-year-old woman presented with a two-month history of recurrent melena and progressive weakness.
History of present illness
Two months prior to admission, the patient developed melena accompanied by progressive weakness. She underwent comprehensive evaluation, including gastroscopy, colonoscopy, contrast-enhanced abdominal computed tomography (CT), and video capsule endoscopy, at an outside institution. Initial gastroscopy and colonoscopy revealed no significant abnormalities. Enhanced abdominal CT and video capsule endoscopy demonstrated multiple large diverticula in the horizontal portion of the duodenum, but no definitive bleeding source. Twenty-four hours before admission, she passed approximately 400 g of melena, with a corresponding haemoglobin (Hb) level of 70 g/L. Emergency gastroscopy revealed fresh blood clots in the descending duodenum, with no definite bleeding source as well.
History of past illness
The patient had no severe underlying diseases, no history of anticoagulant or NSAID use, and no regular alcohol consumption. She had no prior liver disease.
Physical examination upon admission
Vital signs upon admission were as follows: (1) Temperature, 36.7 °C; (2) Heart rate (HR), 90 bpm; (3) Blood pressure, 13.33/8.93 kPa; and (4) Respiratory rate, 21 breaths/minute. The patient was aware but pale in colour. Abdominal examination: (1) Bowel sounds are regular; (2) No tenderness; and (3) No masses are present.
Laboratory examinations
Laboratory studies revealed anaemia with a red blood cell count of 2.55 × 1012/L and a Hb level of 84 g/L. Stool examination revealed red blood cell (+) per high-power field and strongly positive occult blood (4+). Coagulation parameters were within normal limits.
Imaging examinations
Enhanced abdominal CT in our hospital confirmed the presence of multiple duodenal diverticula (DDs) in the horizontal segment (Figure 1A). During the arterial phase, a diverticulum adjacent to the major duodenal papilla exhibited a prominent arterial vessel traversing its wall, without active contrast extravasation (Figure 1B).
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.
MULTIDISCIPLINARY EXPERT CONSULTATION
Treatment upon admission
The patient received intravenous fluids and a proton pump inhibitor. She subsequently developed haematemesis (30 mL) and melena (200 g), and then progressed to haemodynamic shock, presenting with tachycardia (108 bpm), hypotension (10.66/6.93 kPa), and severe anaemia (Hb 50 g/L). The patient was urgently transferred to the intensive care unit, given blood transfusion, and placed under general anaesthesia. Emergency upper gastrointestinal endoscopy was performed using a colonoscope (CF-J01, Olympus, 133 cm) for better visualization of the horizontal duodenum. Two large diverticula were found in the horizontal duodenum, containing food debris, fresh blood clots and scattered erythematous haemorrhagic spots. No active bleeding source was identified after thorough irrigation and careful observation.
Progression of the disease and further diagnostic work-up
After transfusion and support, the patient’s haemodynamics were stable and the Hb level was about 60 g/L. Repeat endoscopy was performed under general anaesthesia with a CFJ01 paediatric colonoscope. Vital signs, including electrocardiography, pulse oxygen saturation, respiratory rate, and non-invasive blood pressure, were monitored at 3-minute intervals. Despite aggressive fluid resuscitation, the patient continued to have persistent tachycardia of 105-110 bpm and mild hypotension at 11.99-12.66/7.33-8.00 kPa. Fresh blood clots were detected within the duodenal lumen, indicating recent or active haemorrhage. The endoscope was temporarily removed to permit endotracheal intubation for airway stabilization, and end-tidal carbon dioxide monitoring was initiated to assist with ventilation and haemodynamic management. Following reinsertion of the endoscope, luminal blood was mostly cleared owing to rapid intestinal peristalsis. Repeated meticulous endoscopic inspection still failed to pinpoint the precise bleeding lesion. Saline irrigation was performed to guarantee a clear endoscopic view, with suction pressure adjusted to -13.33 kPa, which was within the normal range of -10.66 kPa to -16.00 kPa.
Considering recurrent unexplained bleeding and complex anatomy near the duodenal papilla, provocative endoscopy was arranged after multidisciplinary discussion and informed consent. Under monitored anaesthesia, 100 μg phenylephrine[13] was given intravenously, with immediate blood pressure reassessment. Within one minute, blood pressure increased from 11.99/7.33 kPa to 19.46/12.66 kPa, accompanied by reflex bradycardia from 108 bpm to 95 bpm. At peak pressure, a 1-2 mm erythematous spot was seen within a peripapillary DD, with active fresh oozing (Figure 2A); this lesion had been overlooked as a trivial superficial erosion minutes before (Figure 2B).
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.
Phenylephrine was discontinued promptly if severe hypertension (≥ 23.99/16.00 kPa), myocardial ischaemia, or bradycardia < 40 bpm occurred. Highflow oxygen was given with continuous vital sign monitoring. Anaesthetic and gastroenterology teams provided targeted treatment with esmolol, atropine or nitroglycerin as indicated. Surgeons, interventional radiologists, intensive care unit physicians, cardiologists and neurologists were on standby for urgent consultation.
FINAL DIAGNOSIS
Obscure GIB due to a DL located within a DD adjacent to the papilla.
TREATMENT
Endoscopic haemostasis was achieved by submucosal injection of diluted epinephrine (1:10000) around the bleeding point, followed by the placement of three through-the-scope titanium clips to mechanically occlude the vessel (Figure 2C). Haemostasis was confirmed after 5 minutes of observation with irrigation, and no immediate procedure-related complications were observed.
OUTCOME AND FOLLOW-UP
The patient remained haemodynamically stable throughout. Blood pressure returned to baseline within approximately 5 minutes. No procedure-related complications were observed. The patient resumed oral intake with a cool liquid diet on the second postprocedure day and was discharged on hospital day 5 in stable condition, with no further haematemesis or melena. No recurrence of GIB and adverse events were observed during the two months of outpatient follow-up (Figure 3).
DL is a special vascular malformation vulnerable to pressure changes. It manifests as a twisted and enlarged submucosal artery bulging through a small mucosal break[14]. Endoscopy can detect 50%-60% of DLs in the upper gastrointestinal tract when bleeding is ongoing. When bleeding subsides, the retracted vascular stump is covered by normal mucosa, leaving only trivial mucosal changes that are easily overlooked at endoscopy[15]. Common diagnostic examinations have obvious limitations. Angiography requires an active bleeding flow over 0.5 mL/minute to yield positive findings[16], and surgical exploration is mostly empirical when no definite bleeding focus is found. For patients with repeated severe obscure GIB, provocative testing provides a practical alternative for clinical diagnosis[17-20].
Bleeding provocation involves administering pharmacologic agents (anticoagulants, antiplatelet drugs, fibrinolytics, and vasoactive agents) or mechanically removing overlying clots to deliberately induce or augment haemorrhage for real-time source localization during angiography[4,21-27], endoscopy, or scintigraphy (summarized in Table 1)[6-12,17,19,20,28-43]. Provocative angiography, introduced in 1982[8], has been evaluated in at least 26 studies to date, predominantly for small bowel and lower GIB in ten studies[28-37]. The procedure typically employs intra-arterial vasodilators (e.g., tolazoline), anticoagulants (e.g., heparin), or thrombolytics (e.g., tissue plasminogen activator), with contrast extravasation usually observed within 15-30 minutes[7,38,39]. As shown in Table 1, diagnostic yields average of 48.7% in meta-analyses[5], with contemporary series reporting 27.7%-43.8%[40,41]. Serious complications are rare, and three reported cases of massive haemorrhage were controlled by transfusion[8,37,42]. The intestinal ischaemia in one report was attributed to subsequent embolization rather than the provocation strategy itself[23]. While generally safe, the technique has inherent limitations: It is invasive, involves radiation and contrast exposure, and requires a minimum bleeding rate for detection. Current clinical evidence remains limited, and no standardized protocols have yet been established.
Table 1 Pharmacologic provocation for obscure gastrointestinal bleeding.
Advances in endoscopic techniques have facilitated the clinical adoption of provocative endoscopic challenge. These approaches eliminate the need for radiation and contrast medium injection, enable thorough mucosal assessment and targeted biopsy when clinically indicated, and allow careful manipulation of clots to identify obscure bleeding lesions[25]. As illustrated in Table 1, available clinical data are restricted to one case series and four sporadic individual cases[4,9-12]. Substantial discrepancies in diagnostic performance were observed among the three reported regimens. Specifically, the overall positive rate was 27% in antithrombotic-naive patients administered clopidogrel or heparin monotherapy, 53% in those with prior antithrombotic exposure receiving clopidogrel or rivaroxaban as single-agent treatment, and 71% in patients given combined clopidogrel and heparin therapy[4]. A notable limitation of this antithrombotic provocation strategy is its unpredictable bleeding latency, which can range from several hours to multiple days[4,21,44,45]. The observed heterogeneity is largely attributable to interindividual pharmacokinetic variations[4], divergent lesion responses to provocative stimulation[40,43], and inherent differences in drug metabolism among individuals. This unpredictable bleeding propensity is particularly evident in pressure-sensitive arterial lesions, such as DL. Delayed bleeding extends the bleeding risk window, with real-time endoscopic evaluation and close clinical monitoring becoming difficult to conduct. Once local perfusion pressure surpasses the critical threshold, sudden spontaneous haemorrhage is likely to occur. Thus, there remains an unmet clinical demand for a simplified, standardized, and highly reproducible provocative endoscopic protocol.
This case highlights a shift from conventional antithrombotic provocation toward vasopressor-assisted provocative endoscopy for the detection of occult vascular lesions. Endoscopic examination showed fresh clot inside the DD, and CT imaging detected a suspected submucosal vessel. However, repeated endoscopies fail to identify the exact bleeding site. Given the undetermined cause, phenylephrine was administered to raise the patient’s blood pressure artificially. Although it has not been reported in provocative endoscopy before, indirect support for this approach comes from angiographic provocation, where norepinephrine is used for haemodynamic support and occult bleeding foci are inadvertently revealed[23]. Unlike other vasoconstrictors that increase both blood pressure and HR simultaneously, phenylephrine elevates blood pressure without increasing HR and may even trigger reflex bradycardia. Given the patient’s severe anaemia accompanied by hypotension and tachycardia[46,47], phenylephrine was chosen as the most suitable agent for provocation.
As a commonly used vasopressor in procedural anaesthesia, phenylephrine is routinely given as an intravenous bolus of 50-100 μg or a continuous infusion at 10-100 μg/minute[13,46-49]. Excessive dosing may precipitate hypertensive emergency and concomitant bradycardia. The mechanism of vasopressor-provoked bleeding relies on rapid blood pressure elevation, which exceeds the perfusion threshold of fragile vessels and triggers overt haemorrhage. In this case, phenylephrine was administered at the maximum safe bolus dose of 100 μg to achieve the upper safe limit of peak blood pressure elevation. This protocol improved the diagnostic yield of provocation testing while maintaining an optimal balance between provocative efficacy and cardiovascular safety. A 100 μg bolus of phenylephrine elicited a mild, controllable hypertensive rise, with systolic blood pressure increasing by 5.33-6.67 kPa. Acute bleeding rapidly developed from an occult lesion located in the distal DD, whereas systemic blood pressure remained steady within the safe limit of 19.46/12.66 kPa. The dosage applied in this protocol can provide a reference for clinical management of other patients with obscure GIB.
Compared with traditional antithrombotic provocative strategies, vasopressor-assisted endoscopic provocation is more applicable for identifying pressure-susceptible vascular lesions. Phenylephrine allows rapid provocation and precise lesion targeting; bleeding can be induced within 1-2 minutes, permitting immediate endoscopic haemostasis in the same session[48]. This method provides reliable procedural controllability and a relatively short half-life, which helps maintain a sufficient safety margin during endoscopy. In addition, it exerts localized perilesional effects without disturbing the overall systemic coagulation cascade. These strengths effectively address the main shortcoming of antithrombotic provocation: Delayed and unpredictable bleeding onset. Nevertheless, vasopressors can sometimes increase cardiovascular burden in high-risk patients, possibly resulting in severe hypertension, myocardial ischemia and cardiac arrhythmias. Therefore, strict patient screening monitoring are essential. Eligible patients should be haemodynamically stable, presenting with recurrent GIB, strong clinical suspicion of occult vascular lesions, and negative results on routine endoscopic examination. Uncontrolled hypertension, severe coronary artery disease, and previous cerebrovascular events are regarded as relative contraindications. Throughout the procedure, strict adherence to preset safety thresholds, prompt pharmacological management, and multidisciplinary support are mandatory, as described in the Methods section.
Appropriate endoscope selection is essential for detecting distal duodenal lesions. Repeat gastroscopy failed to identify the bleeding source as well as the underlying distal duodenal diverticula. Several studies have shown that adult colonoscopes can be used to evaluate distal duodenal lesions[50-53]. The Olympus colonoscope with a working length of 133 cm can be advanced smoothly to the horizontal duodenum to accurately localize diverticula and achieve effective haemostasis. Compared with enteroscopes, this colonoscope reduces mechanical trauma to the intestinal wall, decreases perforation risk, and improves cost-effectiveness. With this colonoscope, we identified the DL within a distal DD. The lesion corresponded exactly to the arterial focus shown on contrast enhanced CT (Figure 1B). Accordingly, this bleeding provocation protocol can be applied in routine clinical practice without specialized enteroscopy device.
This study also has several limitations. First, it is a single-case study, and thus the generalizability of our findings is limited. Second, we did not collect systematic dose-finding data for phenylephrine, and the optimal dosage protocol was not verified. Third, the follow-up period was confined to just two months; thus, the long-term risk of bleeding recurrence remains unclear. Prospective cohort studies are still needed to establish dosage regimens and safety protocols, define proper patient inclusion criteria, and verify its clinical efficacy and safety in a wider range of clinical scenarios, including gastric vascular ectasia and small bowel angiodysplasia.
Phenylephrine-induced controlled hypertension can trigger bleeding from dormant pressure-sensitive DL safely and effectively. A standard adult colonoscope helps achieve accurate endoscopic localization. This approach is applicable to patients with recurrent obscure GIB and high suspicion of underlying vascular disease, and provides valuable clinical experience for managing similar difficult cases.
CONCLUSION
We report a case in which phenylephrine-induced hypertension provoked subtle bleeding from an occult DL within a DD, enabling accurate endoscopic localization in the quiescent phase using a conventional adult colonoscope. This strategy provides a novel, feasible approach for evaluating recurrent obscure GIB suspected of vascular origin.
ACKNOWLEDGEMENTS
The authors would like to thank the patient and her family for their cooperation. We also appreciate the multidisciplinary collaboration and support provided by colleagues from the Department of Anesthesiology, Interventional Radiology, General Surgery, Intensive Care Unit, Neurology and Cardiology, as well as the nursing team, throughout the procedure.
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