Multiple gastric Dieulafoy lesions in an adolescent female with massive recurrent upper gastrointestinal bleeding: diagnostic and therapeutic challenge - a rare case report.

Introduction: Dieulafoy's lesion is a rare cause of upper gastrointestinal bleeding, accounting for approximately 1-2% of cases. It is characterized by the erosion of an abnormally large submucosal artery through intact mucosa, resulting in sudden and life-threatening hemorrhage. Diagnosis is often difficult due to intermittent bleeding and non-diagnostic initial endoscopy. Case presentation: We report a 17-year-old female with no significant medical history who presented with massive recurrent hematemesis and hemorrhagic shock, with a hemoglobin level of 6.5 g/dL. Upper gastrointestinal endoscopy was initially negative for a bleeding source. Recurrent bleeding prompted further evaluation with contrast-enhanced computed tomography (CT), and CT angiography demonstrated findings highly suggestive of active upper gastrointestinal bleeding originating from the proximal stomach. Despite repeated endoscopic and radiological assessments, bleeding persisted, necessitating exploratory laparotomy. Intraoperatively, multiple dilated perigastric vessels and actively bleeding submucosal arterial lesions were identified in the gastric fundus and proximal body. Gastrotomy and truncal vagotomy with a Heineke-Mikulicz pyloroplasty were performed. Surgical hemostasis was achieved successfully, and the final diagnosis was multiple gastric Dieulafoy lesions. Discussion: Dieulafoy's lesion is an uncommon but important cause of massive upper gastrointestinal bleeding, often difficult to diagnose due to intermittent hemorrhage and normal-appearing mucosa on initial endoscopy. While most cases are managed endoscopically, refractory or recurrent bleeding may require radiological or surgical intervention. This case highlights the importance of maintaining a high index of suspicion and utilizing multimodal imaging when endoscopy is inconclusive. Conclusion: Multiple gastric Dieulafoy lesions are an exceptionally rare cause of massive hematemesis, particularly in adolescents. This case highlights the diagnostic challenge posed by intermittent hemorrhage and initially negative endoscopic findings and underscores the importance of multimodal imaging and timely surgical intervention in refractory cases.