A Challenging Case of Jejunal Dieulafoy's Lesion: A Rare Cause of Refractory Lower-Gastrointestinal Bleeding.

BACKGROUND Dieulafoy's lesion is a rare cause of severe gastrointestinal (GI) bleeding, accounting for approximately 1-2% of all cases of GI hemorrhage. Nevertheless, it can be life-threatening without prompt intervention. Dieulafoy's lesion of jejunal origin can be particularly challenging to identify due to the inability of conventional endoscopic techniques to visualize the jejunum. This case report emphasizes the difficulties in diagnosing and managing jejunal Dieulafoy's lesions and highlights the methods by which to approach refractory bleeding. CASE REPORT This is a case of a 41-year-old man with a history of uncontrolled hypertension who presented with an episode of syncope and melena associated with low hemoglobin levels requiring multiple packed red blood cell transfusions. This warranted searching for a source of bleeding within the gastrointestinal tract via 2 upper-GI endoscopies, a colonoscopy, and an abdominal computed tomography angiogram, all of which failed to localize the site of bleeding. A push enteroscopy was required to identify the lesion in the jejunum, but the bleeding was not controlled despite the application of hemoclips and epinephrine. Consequently, laparotomy and resection of the jejunal segment containing the Dieulafoy's lesion was performed and the diagnosis was established histopathologically. The patient recovered well and was discharged 4 days after the procedure. CONCLUSIONS Suspicion of a jejunal Dieulafoy's lesion should be raised if both upper- and lower-GI endoscopies yield unremarkable findings. Ideally, a push enteroscopy should be utilized diagnostically and to conservatively manage the bleeding. However, laparotomy should be considered in refractory lesions or in the presence of hemodynamic instability.

The addition of silver nitrate cautery to antiseptic nasal cream for patients with epistaxis: A systematic review and meta-analysis.

OBJECTIVE: To compare the outcomes of the addition of silver nitrate cautery versus antiseptic cream alone in paediatric patients with recurrent epistaxis. METHODS: A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines and a search of electronic information was conducted to identify all Randomised Controlled Trials (RCTs) and non-randomised studies comparing the outcomes of the addition of silver nitrate cautery versus antiseptic cream alone in paediatric patients with recurrent epistaxis. Treatment success and persistence of bleeding were primary outcome measures. Secondary outcome measures included treatment side effects. Fixed effects modelling was used for the analysis. RESULTS: Four studies enrolling 240 patients were identified. There was no significant difference between silver nitrate cautery group and antiseptic cream alone group in terms of complete resolution (Odds Ratio [OR] = 1.07, P = 0.81), the partial resolution (OR = 1.02, P = 0.96) and persistence of bleeding (OR = 0.91, P = 0.71). For secondary outcomes, antiseptic nasal cream was associated with few side effects such as rash in one case and several complaints of bad smell or taste. CONCLUSIONS: The addition of silver nitrate cautery is not superior to the use of antiseptic cream alone in paediatric patients with recurrent epistaxis as it does not improve treatment success or persistence of bleeding.