Dieulafoy's Lesion of the Major Duodenal Papilla Presenting as Obscure Upper Gastrointestinal Bleeding: A Case Report

Dieulafoy's lesion is an uncommon vascular anomaly that can cause life‐threatening gastrointestinal bleeding. While the stomach is the most frequently affected site, involvement of the major duodenal papilla is exceedingly rare and may escape detection with conventional forward‐viewing endoscopy. We report a rare case of papillary Dieulafoy's lesion presenting as obscure upper gastrointestinal bleeding in a patient receiving rivaroxaban. A 69‐year‐old woman with deep vein thrombosis receiving rivaroxaban, hypertension, and hypothyroidism presented with recurrent melena and severe anemia (hemoglobin 5.8–7.1 g/dL). Despite extensive evaluation, including capsule endoscopy, colonoscopy, and two forward‐viewing esophagogastroduodenoscopies, no bleeding source was identified. Persistent anemia and fresh blood in the second portion of the duodenum raised suspicion of a periampullary bleeding source. Side‐viewing duodenoscopy subsequently identified a 1 × 1 mm erythematous lesion with active bleeding at the major duodenal papilla, consistent with a Dieulafoy's lesion. Combination endoscopic therapy with epinephrine injection, bipolar thermal coagulation, and hemoclip placement achieved complete hemostasis. Rivaroxaban was temporarily discontinued, and no recurrent bleeding or post‐procedural pancreatitis occurred during 6 months of follow‐up. This case highlights the diagnostic challenge of papillary Dieulafoy's lesions when conventional forward‐viewing endoscopy is non‐diagnostic. Early side‐viewing duodenoscopy is essential when a periampullary bleeding source is suspected, and combination endoscopic therapy can provide durable hemostasis, even in anticoagulated patients.