An unusual cause of massive upper gastrointestinal bleeding: Dieulafoy's lesion within a giant midesophageal diverticulum.

asymptomatic and are often discovered incidentally during endoscopy performed for unrelated reasons. A small proportion present with life−threatening bleeding. We present here a first report of the mas− sive arterial bleeding from Dieulafoy’s le− sion in a midesophageal diverticulum. A 63−year−old man presented with repeat− ed vomiting of fresh blood. Urgent endos− copy revealed a giant midesophageal di− verticulum at 28 cm from the incisor teeth, within which active bleeding from a protruding vessel without surrounding ulceration was seen (l" Fig. 1). The endo− scopic features were compatible with a Dieulafoy’s lesion. Endoscopic injection therapy was performed with epinephrine (1: 10 000 dilution) and polidocanol (1%). However, hemostasis was not achieved and spurting arterial bleeding started (l" Fig. 2). Three hemoclips were immedi− ately applied directly to the vessel, despite which bleeding could not be controlled. The procedure was terminated because of the high risk of esophageal perforation. Angiographic embolization and surgery were precluded. The bleeding could be controlled with insertion of a Sengsta− ken−Blakemore tube. The thorax comput− ed tomography scan revealed a huge mid− esophageal diverticulum but no evidence of an aortoesophageal fistula (l" Fig. 3). A follow−up esophagogastroduodenoscopy on day 10 revealed a well−demarcated ul− cer covered by a whitish−gray exudate in the location of the previous bleeding point (l" Fig. 4). This ulcer was considered sec− ondary to the application of sclerosing agent. The last endoscopic follow−up, per− formed 1 month later, showed nearly complete healing of the lesion within the diverticulum (l" Fig. 5). Esophageal Dieulafoy’s lesion is very rare and the most common site is the distal esophagus [1]. The use of the Sengsta− ken−Blakemore tube to control massive hemorrhage from a Dieulafoy’s lesion in the lower esophagus has been described previously [2]. To our knowledge, this re− presents the first patient with bleeding Dieulafoy’s lesion in a midesophageal di− verticulum successfully managed with a Sengstaken±Blakemore tube as a rescue therapy in a patient after failed endo− scopic intervention.