Massive Hematemesis: An Uncommon Presentation of an Unusual Diagnosis

A 74-year-old male presented to the emergency department following several episodes of hematemesis and hematochezia. The patient was on dabigatran for chronic atrial fibrillation. Physical examination revealed pallor, tachycardia, and hypotension with a systolic blood pressure of 87 mm Hg. Laboratory blood tests showed a hemoglobin level of 8.8 g/dL, urea of 36 mg/dL, and creatinine of 1.06 mg/dL. The patient responded to the initial resuscitative measures, requiring idarucizumab and 2 units of red blood cells, and underwent an upper gastrointestinal endoscopy that revealed fresh blood in the stomach and duodenum without signs of an active bleeding lesion. The patient subsequently experienced a second episode of hemodynamically significant hematemesis and hematochezia requiring additional transfusion support. Upper gastrointestinal endoscopy was repeated soon thereafter, but it was once again inconclusive. Ultimately, the patient developed shock, and a computed tomography (CT) angiography was performed, showing an actively bleeding jejunal lesion on the CT angiography (Fig. 1). The patient underwent a laparotomy that uncovered a diverticulum on the mesenteric border of the proximal jejunum, 30 cm distal to the ligament of Treitz, with an apparent intraluminal bleeding. There was rapid hemodynamic improvement after surgical resection (Fig. 2). Histopathology disclosed a pseudo-diverticulum with a dilated submucosal artery protruding through normal surrounding mucosa that ruptured into the intestinal lumen (Fig. 3), compatible with a Dieulafoy’s lesion in a jejunal diverticulum. Small-bowel diverticulosis is an uncommon condition, with an estimated incidence of 0.4–4.6% [1]. It is usually an asymptomatic condition, typically arising on the mesenteric border of the bowel [1]. Rarely, it can be