A Bleeding Dieulafoy’s Lesion in the Distal Stomach with Incidental Gastric and Duodenal Bulb Pseudomelanosis

A Bleeding Dieulafoy’s Lesion in the Distal Stomach with Incidental Gastric and Duodenal Bulb Pseudomelanosis

Qasim Abbas *1, Jawahir Lal 1, Mohamad Alnassar 1

 

  1. GI unit, Sultan Qaboos University Hospital, Muscat, Oman.

 

*Correspondence to: Qasim Abbas. GI unit, Sultan Qaboos University Hospital, Muscat, Oman.


Copyright.

© 2026 Qasim Abbas, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 10 May 2026

Published: 01 June 2026

DOI: https://doi.org/10.5281/zenodo.20472561


A Bleeding Dieulafoy’s Lesion in the Distal Stomach with Incidental Gastric and Duodenal Bulb Pseudomelanosis

Case Description

A 76-year-old woman with hypertension, diabetes mellitus, stage 3 chronic kidney disease, heart failure and atrial fibrillation. She was on multiple medications including Hydralazine. She presented with melena and syncope. Initial hemoglobin was 7.2 g/dL.

After resuscitation, emergent upper endoscopy revealed a 2-mm vessel with active pulsatile bleeding was identified in the distal stomach (pre-antral region) without associated ulcer suggestive of a Dieulafoy’s lesion (Figure 1A). Hemostasis was achieved using two through-the-scope clips (Figure 1B).

During the same procedure, two incidental findings of pseudomelanosis were noted on the lesser curve gastric wall (Figure 2A) and duodenal bulb (Figure 2B). The antrum was uninvolved.


The patient recovered uneventfully with no rebleeding.

 

Discussion

Dieulafoy’s lesions can occur in the distal stomach which is an atypical location that should not be overlooked. Endoscopic clipping is first line therapy1. The typical appearance is a visible vessel with active pulsatile bleeding without associated ulcer[1-2].

Gastroduodenal pseudo melanosis is a rare, benign incidental finding characterized by brown-black mucosal speckling. It has been described in patients with chronic kidney disease and oral iron therapy.[3-4] In addition, Hydralazine and CKD are more consistently and strongly associated with GI melanosis[5].

Biopsies were not taken given the classic appearance. The patient was diagnosed with multifocal gastroduodenal pseudomelanosis in two distinct locations (lesser curve gastric wall and duodenal bulb) with spared antrum – an unusual pattern that should not be mistaken for pathology requiring biopsy.

 

References

  1. Barkun AN, Laine L, Leontiadis GI, et al. Canadian Association of Gastroenterology Clinical Practice Guideline for the Endoscopic Management of Nonvariceal Nonpeptic Ulcer Upper Gastrointestinal Bleeding. Gastroenterology. 2025;169(5):863.
  2. Lee YT, Walmsley RS, Leong RW, Sung JJ. Dieulafoy's lesion. Gastrointest Endosc. 2003;58(2):236-243.
  3. Ting WY, Chua CL, Yeoh KG. An Incidental Finding of Gastric and Duodenal Pseudomelanosis: A Case Report. Cureus. 2022;14(1): e21264.
  4. Khan K, Boktor M, Chaudoir C, Alexander S. Gastric and Duodenal Pseudomelanosis in a Patient with Chronic Kidney Disease and Oral Iron Supplementation. Am J Gastroenterol. 2017;112: S987-S988.
  5. Novikov, A., et al. Hydralazine -Induced Vasculitis with Gastrointestinal Pseudomelanosis. ACG Case Reports Journal, October 2014.