Successful side-viewing endoscopic hemoclipping for Dieulafoy-like lesion at the brim of a periampullary diverticulum

Duodenal Dieulafoy's lesions are rare and only several cases were reported so far. Their characteristic appearance and location make it difficult to be diagnosed in the clinical practice. Massive bleeding often results from these lesions and can impede the accurate early treatment. 67 years old male patient suffered a fatal bleeding from Dieulafoy-like lesion located at the mouth of the periampullary diverticulum. Initial endoscopic therapy and radiologic embolization failed to stop the bleeding, while direct observation and hemoclipping by the side viewing endoscopy successfully established correct diagnosis and permanent cure of the lesion. Aggressive endoscopic examinations combined with the accurate endoscopic treatment should be adopted when Dieulafoy-like lesion is suspected as a possible cause of the proximal small bowel hemorrhage. Verification of the diagnosis and definitive treatment often needed repeated examination by side-viewing endoscope as well as stabilization of the patient.