Intraoperative Enteroscopy After Repeated Negative Endoscopy for a Pediatric Small- Bowel Dieulafoy-Type Lesion: A Case Report

Intraoperative Enteroscopy After Repeated Negative Endoscopy for a Pediatric Small- Bowel Dieulafoy-Type Lesion: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Intraoperative Enteroscopy After Repeated Negative Endoscopy for a Pediatric Small- Bowel Dieulafoy-Type Lesion: A Case Report Fredy Makele, Yi Yang, Wenqiang Zhang, Yuchen Zhang, Jin Zhe, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8929921/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Dieulafoy-type vascular lesions of the small bowel are rare but important causes of gastrointestinal bleeding in children. Localization is particularly difficult in cases presenting with chronic occult bleeding and progressive anemia when conventional endoscopy and imaging fail to identify the source. Case presentation We report a toddler girl with a 9-month history of persistent fecal occult blood positivity and worsening anemia requiring repeated transfusions. A broad diagnostic work-up was undertaken, including upper and lower endoscopy, imaging studies, and nuclear medicine investigations, but none of these examinations identified a definite bleeding source. Given the ongoing occult blood loss and continued clinical deterioration, exploratory surgery with intraoperative enteroscopy was performed. This revealed multiple submucosal vascular lesions with focal hemorrhagic changes involving the duodenum and small intestine. Histopathological analysis confirmed a vascular malformation associated with heterotopic gastric mucosa. The patient recovered well after surgery, with normalization of hemoglobin levels and disappearance of fecal occult blood. A second institutional pediatric case is also included to highlight the contrasting diagnostic role of routine endoscopy. In addition, we reviewed previously published pediatric cases of occult and difficult-to-localize Dieulafoy-type lesions for comparison. Conclusion In young children with chronic obscure gastrointestinal bleeding and negative routine investigations, small-bowel vascular lesions should be considered. When conventional endoscopic approaches fail, intraoperative enteroscopy can be a decisive diagnostic tool for identifying otherwise occult lesions and guiding management. Dieulafoy lesion occult gastrointestinal bleeding intraoperative enteroscopy pediatric anemia small bowel Figures Figure 1 Figure 2 Introduction Dieulafoy lesion (DL) is an uncommon but potentially life-threatening cause of gastrointestinal bleeding, resulting from erosion of a large-caliber submucosal artery through a small mucosal defect( 1 ). DL most commonly occurs in the stomach, particularly along the lesser curvature, where 80% to 95% of cases are located within 6 cm of the gastroesophageal junction( 2 – 6 ). This predilection is believed to reflect the local vascular architecture. In this region, relatively large-caliber arterial branches arise directly from the left gastric arterial chain and penetrate the submucosa without undergoing the normal gradual tapering seen elsewhere in the stomach( 3 , 7 ). In contrast, other areas are supplied predominantly by a dense submucosal vascular plexus, which may reduce the likelihood of focal arterial exposure ( 8 , 9 ). Although gastric DL accounts for the majority of cases, extragastric involvement has been increasingly recognized. DL has been reported in the duodenum and colon ( 10 , 11 ), as well as in the esophagus, small bowel, rectum, and anal canal ( 4 , 12 , 13 ). Rare extra-gastrointestinal occurrences, including bronchial DL, have also been described ( 14 , 15 ). Historically, surgical exploration was the primary method for diagnosis and treatment( 8 , 18 ). With advances in endoscopic techniques, management has shifted substantially, and endoscopy is now considered the first-line approach, enabling successful identification and hemostasis in most cases( 7 ).However, diagnostic challenges persist in pediatric patients, particularly when DL involves the small bowel ( 5 , 16 ). Here, we report a pediatric case of chronic occult gastrointestinal bleeding in early childhood in which repeated endoscopic and imaging investigations failed to localize the bleeding source, and the lesion was ultimately identified through surgical exploration combined with intraoperative enteroscopy. A second institutional case is presented to illustrate the complementary diagnostic role of conventional endoscopy. In addition, we include a focused review of previously reported pediatric cases of occult and difficult-to-localize DL to provide clinical context. This case report was prepared in accordance with the CARE guidelines “ This case report was prepared in accordance with the CARE guidelines ( https://www.care-statement.org )” Case presentation CASE 1 A 2-year-old girl was admitted with a 9-month history of persistent fecal occult blood positivity and progressive anemia, consistent with chronic obscure gastrointestinal bleeding. During this period, she experienced intermittent dark stools without hematemesis, abdominal pain, fever, or other systemic symptoms. Her anemia gradually worsened and required repeated hospital evaluations and transfusion support. The patient had a complex neonatal history. Shortly after birth, she underwent abdominal surgery for multiple congenital anomalies, including omphalocele, jejunal cystic dilatation, intestinal malrotation, and congenital absence of the gallbladder. Surgical management included resection of abnormal jejunum with primary anastomosis and Ladd’s procedure. She also had congenital heart disease (atrial septal defect and patent ductus arteriosus). Postoperative recovery during infancy was satisfactory. Approximately nine months before the current admission, persistent fecal occult blood positivity was noted during outpatient follow-up, accompanied by progressive pallor. Laboratory evaluation confirmed severe chronic blood loss anemia, with a hemoglobin nadir of 65 g/L (reference 110–140 g/L) and red blood cell count of 2.36 ×10¹²/L (reference 3.8–5.2 ×10¹²/L). On admission, hemoglobin remained markedly reduced at 72 g/L and increased only to 83–90 g/L following transfusion support, indicating ongoing occult bleeding. Platelet count was 277 ×10⁹/L (reference 150–400 ×10⁹/L), and white blood cell count was within normal range (reference 5.0–12.0 ×10⁹/L). Coagulation parameters were preserved, including prothrombin time 13.6 s (reference 11–14 s), fibrinogen 2.31 g/L (reference 2.0–4.0 g/L), and D-dimer 0.26 µg/mL (reference < 0.5 µg/mL). Physical examination demonstrated marked pallor with stable vital signs. Abdominal examination was unremarkable aside from a well-healed surgical scar. Imaging studies revealed postoperative changes in the small bowel, including segmental wall thickening and localized dilatation. Previous upper and lower endoscopy demonstrated nonspecific inflammatory findings (chronic gastritis, duodenitis, and colitis) without identification of a bleeding source. Nuclear medicine SPECT imaging showed tracer retention in the right upper abdomen, suggesting a small-bowel origin; however, the bleeding focus remained unidentified. Given persistent transfusion-dependent anemia and ongoing occult blood loss, a multidisciplinary discussion involving pediatric surgery, gastroenterology, hematology, and radiology was conducted. A small-bowel bleeding source beyond the reach of conventional endoscopy was suspected, and exploratory surgery combined with intraoperative enteroscopy was recommended. Under general anesthesia, intraoperative gastroscopy revealed nonspecific mucosal thickening in the distal duodenum without active bleeding (Fig. 1 A). Exploratory laparotomy was subsequently performed. The previous jejunal anastomosis was patent, with proximal bowel dilatation noted, but no external lesions were visible. An enterotomy was created near the dilated jejunal segment, and intraoperative enteroscopy identified a focal submucosal hemorrhagic lesion in the descending duodenum, consistent with a Dieulafoy-type vascular abnormality and the presumed source of chronic bleeding (Fig. 1 B). Additional small submucosal hemorrhagic spots suggestive of prior bleeding were observed in the distal small bowel. The lesion was marked under enteroscopic guidance to delineate the resection margin (Fig. 2A). Segmental small-bowel resection was then performed. Gross examination of the resected specimen demonstrated a focal hemorrhagic region corresponding to the identified lesion (Fig. 2B). Histopathological examination of full-thickness specimens from the duodenum and small bowel revealed submucosal vascular malformation characterized by irregular, distorted vessels with uneven wall thickness. The duodenal specimen also demonstrated heterotopic gastric mucosa with focal hemorrhage. Mesenteric lymph nodes showed reactive hyperplasia without evidence of malignancy. Postoperatively, the patient received supportive management in the intensive care unit, including gastric decompression, nutritional support, and acid suppression therapy. Hemoglobin levels stabilized without further significant decline. Transient postoperative vomiting associated with partial intestinal obstruction resolved with conservative treatment. Follow-up fecal occult blood tests became negative, hemoglobin remained stable without additional transfusion, and no recurrent gastrointestinal bleeding was observed during follow-up. Case 2 A 2-year-10-month-old boy (weight 15.0 kg) was admitted with fever, cough, and generalized urticaria and was initially diagnosed with sepsis and acute upper respiratory tract infection. On admission, the child appeared pale but was hemodynamically stable. Abdominal examination showed no distension, tenderness, or palpable masses, and no external vascular malformations were identified. Laboratory evaluation demonstrated leukocytosis and elevated inflammatory markers (white blood cell count 15.22 ×10⁹/L [reference 5.0–12.0 ×10⁹/L]; C-reactive protein 27.15 mg/L [reference < 8 mg/L]). Hemoglobin progressively declined to 74 g/L (reference 110–140 g/L), and platelet count increased to 455 ×10⁹/L (reference 150–400 ×10⁹/L), consistent with reactive thrombocytosis secondary to inflammation and blood loss. After stabilization of the infectious process, endoscopic evaluation was undertaken due to persistent anemia and ongoing fecal occult blood positivity. Routine upper gastrointestinal endoscopy identified a focal actively bleeding lesion in the proximal small bowel, morphologically consistent with a Dieulafoy-type submucosal vascular abnormality. Hemostasis was successfully achieved using endoscopic clipping. Following the intervention, the child’s condition stabilized without procedural complications. Hemoglobin levels improved with supportive care, and no recurrent gastrointestinal bleeding was observed during the remainder of hospitalization. The patient was discharged in stable condition. Discussion Obscure gastrointestinal bleeding in early childhood presents a significant diagnostic challenge in pediatric gastroenterology( 7 , 16 , 19 , 20 ). While Dieulafoy lesions (DL) are rare, they have become increasingly recognized as an important cause of gastrointestinal hemorrhage( 13 , 16 , 17 , 21 , 22 ). Among the proposed mechanisms, a congenital vascular anomaly is most commonly suggested, in which an unusually large-caliber submucosal artery persists as it penetrates the gastric wall, increasing susceptibility to abrupt and severe bleeding. This hypothesis is supported by reports of DL occurring even in neonates( 5 , 23 ). To date, there is no universal consensus regarding the optimal management of DL; therefore, treatment selection is largely guided by lesion location, bleeding severity, and the availability of appropriate endoscopic or surgical expertise( 9 ). Endoscopy is considered the gold standard for diagnosis and treatment. Advances in endoscopic imaging and therapeutic techniques have improved diagnostic yield to approximately 70%, and treatment success rates for hemostasis approach 90%( 9 , 24 – 27 ). Historically, mortality associated with Dieulafoy lesions ranged from 23% to 79%, but with modern endoscopic management, it has decreased to less than 10%( 9 , 28 ) Despite these advances, a clinically important subgroup of patients continues to present with persistent bleeding and repeatedly negative routine investigations( 13 , 16 , 17 , 26 , 29 ). In the primary case, the clinical course was characterized by prolonged fecal occult blood positivity, progressive transfusion-dependent anemia, and multiple nondiagnostic evaluations. This differs from more common pediatric presentations, which typically involve acute bleeding identified during early endoscopic examination. In this patient, the bleeding source was localized in the small bowel, and definitive identification was achieved only through intraoperative enteroscopy. The second institutional case contrasts with the primary case, as it involved successful identification through routine endoscopic evaluation. This illustrates the efficacy of endoscopy as the first-line diagnostic and therapeutic modality. In cases like these (Table 1 , Group A ), standard endoscopic methods, such as argon plasma electrocoagulation, photocoagulation, and the use of clips or bands to close abnormal vessels, are highly effective in controlling bleeding.( 6 , 11 , 22 , 24 – 26 , 30 ) Group A: Endoscopically localized and treated cases Table 1 , The cases summarized in Group A reflect the more typical pediatric presentation of Dieulafoy lesions, often found in the stomach or proximal duodenum and diagnosed through routine endoscopy. These cases align with broader evidence, showing high success rates for endoscopic hemostasis in controlling bleeding Reference Age (y) Sex Bleeding presentation Lesion location Hb nadir (g/L) Transfusion Key diagnostic modality Definitive therapy Kostopoulou (2020)( 24 ) 15.0 Female Hematemesis Stomach—body 100 Yes Endoscopy Clip Ribeiro (2024)( 25 ) 16.0 Male Hematemesis with melena and syncope Stomach—fundus 67 Yes Endoscopy Clip+Injection Emura (2016)( 26 ) 2.0 Male Massive hematemesis Stomach—lower body 80 No Endoscopy Clip Liu (2022)( 6 ) 8.0 Male Massive hematemesis Stomach—fundus NR NR Emergency gastroscopy Clip Chen (2022)( 27 ) 10.0 Female Massive hematemesis and melena Stomach—body (posterior wall) 7.8→6.9 Yes Gastroscopy Clip+Thermal/APC Di Nardo (2020)( 22 ) 1.5 Female Hematemsis + melena with worsening anemia Stomach—body–fundus junction 88 NR EGD Band Di Nardo (2020)( 22 ) 8.0 Male Sudden massive hematemesis + melena; shock Stomach—lesser curvature (near antrum) 68 Yes EGD Clip However, multiple endoscopies may be necessary to detect the bleeding source, with up to 6% of patients requiring three or more procedures( 2 , 17 , 30 ). The source may remain undetected because lesions are small, subtle, intermittently bleeding, or anatomically inaccessible ( 9 , 13 ). Push enteroscopy, an extension of upper gastrointestinal endoscopy, can help assess the small intestine up to 150 cm from the pylorus, offering deeper evaluation when conventional endoscopy is insufficient.( 26 ) When endoscopy fails, angiography is a valuable alternative, particularly for lower gastrointestinal lesions.( 31 ) Angiographic findings often show extravasation of contrast from an eroded artery, which may appear normal, tortuous, or ectatic. Angiography also serves as a second-line treatment ( Table 2 , Group B ), allowing embolization to stop bleeding when endoscopic methods fail.( 10 , 16 , 20 , 24 ) Group B: Difficult-to-localize / occult or advanced-diagnostic cases Table 2 Summary of pediatric Dieulafoy-type lesions (DL) presenting with chronic or obscure gastrointestinal bleeding. Unlike classical presentations, which involve acute hematemesis or melena with rapid endoscopic localization, these cases are characterized by prolonged anemia, recurrent transfusion requirements, and repeated negative initial investigations. Lesions are often located in the small bowel or other anatomically less accessible regions, contributing to diagnostic delays. Multiple endoscopic evaluations, advanced imaging techniques, angiography, and, in some cases, surgical exploration or intraoperative enteroscopy were required to identify the bleeding source. Reference Age (y) Sex Bleeding presentation Lesion location Hb nadir (g/L) Transfusion Key diagnostic modality Failed diagnostic modality Definitive therapy Shang (2015) 15.0 Male Hematemesis + melena + dizziness Duodenum 105 Yes angiography Emergent gastroscopy Injection + Embolization Shibutani (2011) 14.0 Female Massive hematochezia with syncope Ileum 84 Yes intraoperative fluoroscopy EGD Surgery + Embolization Alomari (2013) 14.0 Female Melena + syncope + fatigue + nausea Duodenum NR Yes Angiography capsule endoscopy +push-enteroscopy+ intra-operative pan-enteroscopy Embolization Jurić‑Kavelj (2021) 13.0 Male Recurrent hematemesis + hemorrhagic shock Stomach 106 Yes Endoscopy → surgery confirmation push enteroscope Clip +Injection + laparotomy Iwamoto (2021) 15.0 Female Melena + presyncope + convulsions → hemorrhagic shock Ileal anastomosis 67 Yes CT + endoscopy + intraoperative identification — + Surgery Moreira-Pinto (2009) 14.0 Female Hematochezia + syncope → hemorrhagic shock Ileum 100 Yes laparotomy diagnosis colonoscopy+ upper digestive endoscopy Surgery Salakos (2015) 0.18 Male Massive hematemesis Stomach 100 Yes surgical identification Multiple Endoscopy Endoscopic therapy + Surgery Jean (2023) 15.0 Male 5-day history melena, fatigue, weakness Transverse colon 69 NR colonoscopy capsule endoscopy+ angiography + Injection+ thermocoagulation While surgical resection was once the first-line treatment for Dieulafoy lesions, it is now reserved as a last resort, used in about 5% of cases where endoscopy or angiography fails to control the bleeding( 5 , 13 , 16 , 17 , 29 , 32 ). In such cases, laparotomy or laparoscopy, combined with intraoperative endoscopy, may serve as both a diagnostic and therapeutic modality (Table 2 , Group B ), Intra-operative enteroscopy enables direct evaluation of the small intestine with a diagnostic yield of 70–100% in patients with obscure GI bleeding( 13 ). This approach allows real-time assessment of the bowel, guiding surgical intervention and improving the likelihood of lesion localization. ( 9 , 33 ) However, even intraoperative enteroscopy is not invariably definitive, as lesions may remain elusive due to intermittent hemorrhage or subtle mucosal findings. In some reports, extensive investigations—including capsule endoscopy, push enteroscopy, exploratory laparotomy, and intraoperative pan-enteroscopy failed to identify a specific bleeding source, ultimately necessitating angiography and embolization for localization and treatment( 20 ). Conclusion From a clinical perspective, this study highlights a practical diagnostic pathway. In children with chronic unexplained anemia and ongoing occult gastrointestinal bleeding, repeated negative endoscopic findings should not lead to premature diagnostic closure. When bleeding persists and transfusion requirements continue, intraoperative enteroscopy may serve as both a diagnostic and therapeutic modality, enabling direct visualization of lesions that cannot be detected through nonoperative techniques. Declarations Ethics Approval and Consent to Participate This case reports complies with all ethical guidelines. Ethical approval was not required for this study as per institutional policies, but informed consent was obtained from the patient’s guardians to share their anonymized medical information. Clinical trial number: Not applicable. Consent for Publication Written informed consent for publication of this case report and any accompanying images was obtained from the patient’s guardians. Competing Interests The authors declare that they have no competing interests. Funding This study was supported by the Zhejiang Medical and Health Project (2021PY014) and the Basic Public Welfare Research Program of Zhejiang Province (LGF21H040009). Author Contribution F.M. (Fredy Makele): Conceptualized the study, collected clinical data, and drafted the manuscript.Y.Y. (Yi Yang) and W.Q.Z. (Wenqiang Zhang): Conducted the literature review and contributed to drafting and revising the manuscript.Y.C.Z. (Yuchen Zhang), J.Z. (Jin Zhe), and Z.X.W. (Zhouxu Wang): Reviewed and revised the manuscript for important intellectual content and contributed to preparation of the discussion.L.B.Z.* (Libin Zhu): Corresponding author; supervised the study, provided critical analysis, and contributed substantially to the final manuscript revisions. 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J Surg Res. 2009;155(2):318–20. 10.1016/j.jss.2008 . 06.046 PubMed PMID: 19482295. Sai Prasad TR, Chui CH, Jacobsen AS. Laparoscopic appendicectomy in children: A trainee’s perspective. Ann Acad Med Singap. 2006;35(10):694–7. PubMed PMID: 17102892. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 22 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers invited by journal 22 Apr, 2026 Editor invited by journal 23 Feb, 2026 Editor assigned by journal 21 Feb, 2026 Submission checks completed at journal 21 Feb, 2026 First submitted to journal 20 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8929921","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":633440796,"identity":"fa1d4b5a-d619-4e6e-a31f-a5efb7ab24a3","order_by":0,"name":"Fredy Makele","email":"","orcid":"","institution":"Second Affiliated Hospital \u0026 Yuying Children's Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Fredy","middleName":"","lastName":"Makele","suffix":""},{"id":633440797,"identity":"11d239ec-3c84-4dbe-a73c-9e5823ef071c","order_by":1,"name":"Yi Yang","email":"","orcid":"","institution":"Second Affiliated Hospital \u0026 Yuying Children's Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Yang","suffix":""},{"id":633440798,"identity":"99f34dd5-0f3a-4e2b-8724-3de1dc41d1ab","order_by":2,"name":"Wenqiang Zhang","email":"","orcid":"","institution":"Second Affiliated Hospital \u0026 Yuying Children's Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wenqiang","middleName":"","lastName":"Zhang","suffix":""},{"id":633440799,"identity":"549c73a8-1110-42f1-b33e-5c6f4c9c67b1","order_by":3,"name":"Yuchen Zhang","email":"","orcid":"","institution":"Second Affiliated Hospital \u0026 Yuying Children's Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuchen","middleName":"","lastName":"Zhang","suffix":""},{"id":633440800,"identity":"c6ee1786-036e-4a3d-8cca-6577672eff2b","order_by":4,"name":"Jin Zhe","email":"","orcid":"","institution":"Second Affiliated Hospital \u0026 Yuying Children's Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Zhe","suffix":""},{"id":633440801,"identity":"c27f8f8c-f132-4e27-926e-7088d7c272de","order_by":5,"name":"Zhouxu Wang","email":"","orcid":"","institution":"Second Affiliated Hospital \u0026 Yuying Children's Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhouxu","middleName":"","lastName":"Wang","suffix":""},{"id":633440802,"identity":"51a77f06-ed4d-4dda-956d-85cd701ac08b","order_by":6,"name":"Libin Zhu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYDACCSB+YHCAh4G9AcxnbCBKSwJIC88BkrQwAJVLJBCpRX52jwFDQsEdGXPJN6abeRhsZDccYH72AJ8WxjlngFoMnvFYzs4xu83DkGa84QCbuQE+LcwSOSAth3kMbuduA2o5nLjhAA+bBD4tbHAtN8+CtPwnrIUHruUGL0jLAcJaJCTSCsB+MTiT/+3mHINk45mH2czwapGfkbyB4cOfO/YGx4+l3XhTYSfbd7z5GV4tQMD+A8EGBRUzAfWjYBSMglEwCggDADsdRz/iYCbaAAAAAElFTkSuQmCC","orcid":"","institution":"Second Affiliated Hospital \u0026 Yuying Children's Hospital of Wenzhou Medical University","correspondingAuthor":true,"prefix":"","firstName":"Libin","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2026-02-21 02:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8929921/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8929921/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108725388,"identity":"c40dab07-b242-40af-9c19-2342312cc6c6","added_by":"auto","created_at":"2026-05-07 16:55:36","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":442798,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEndoscopic evaluation of the duodenal lesion.\u003c/strong\u003e\u003cbr\u003e\n(A) Intraoperative gastroscopy showing nonspecific mucosal thickening without an actively bleeding focus.\u003cbr\u003e\n(B) Intraoperative enteroscopy revealing a focal submucosal hemorrhagic lesion consistent with a Dieulafoy-type vascular abnormality.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8929921/v1/c23feff48689c6f3f459fcd1.jpeg"},{"id":108725391,"identity":"84baba02-43e4-4c80-86d0-29fab455ed27","added_by":"auto","created_at":"2026-05-07 16:55:38","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":258250,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntraoperative localization and surgical resection.\u003c/strong\u003e\u003cbr\u003e\n(A) Enteroscopic guidance with intraoperative marking of the suspected bleeding site to define resection margins.\u003cbr\u003e\n(B) Gross appearance of the resected small-bowel specimen demonstrating a focal hemorrhagic region corresponding to the lesion.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8929921/v1/334f2f91dee78a9b1bb7a0f1.jpeg"},{"id":108725479,"identity":"49099fb8-2ef4-43e3-9a54-cbd7fe41066c","added_by":"auto","created_at":"2026-05-07 16:55:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":993055,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8929921/v1/1c5b9dd0-3945-4eb5-a168-6f5b9646e5d2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Intraoperative Enteroscopy After Repeated Negative Endoscopy for a Pediatric Small- Bowel Dieulafoy-Type Lesion: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDieulafoy lesion (DL) is an uncommon but potentially life-threatening cause of gastrointestinal bleeding, resulting from erosion of a large-caliber submucosal artery through a small mucosal defect(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). DL most commonly occurs in the stomach, particularly along the lesser curvature, where 80% to 95% of cases are located within 6 cm of the gastroesophageal junction(\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This predilection is believed to reflect the local vascular architecture. In this region, relatively large-caliber arterial branches arise directly from the left gastric arterial chain and penetrate the submucosa without undergoing the normal gradual tapering seen elsewhere in the stomach(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In contrast, other areas are supplied predominantly by a dense submucosal vascular plexus, which may reduce the likelihood of focal arterial exposure (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough gastric DL accounts for the majority of cases, extragastric involvement has been increasingly recognized. DL has been reported in the duodenum and colon (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), as well as in the esophagus, small bowel, rectum, and anal canal (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Rare extra-gastrointestinal occurrences, including bronchial DL, have also been described (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHistorically, surgical exploration was the primary method for diagnosis and treatment(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). With advances in endoscopic techniques, management has shifted substantially, and endoscopy is now considered the first-line approach, enabling successful identification and hemostasis in most cases(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).However, diagnostic challenges persist in pediatric patients, particularly when DL involves the small bowel (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHere, we report a pediatric case of chronic occult gastrointestinal bleeding in early childhood in which repeated endoscopic and imaging investigations failed to localize the bleeding source, and the lesion was ultimately identified through surgical exploration combined with intraoperative enteroscopy. A second institutional case is presented to illustrate the complementary diagnostic role of conventional endoscopy. In addition, we include a focused review of previously reported pediatric cases of occult and difficult-to-localize DL to provide clinical context. This case report was prepared in accordance with the CARE guidelines \u003cb\u003e\u0026ldquo;\u003c/b\u003eThis case report was prepared in accordance with the CARE guidelines \u003cb\u003e(\u003c/b\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.care-statement.org\u003c/span\u003e\u003cspan address=\"https://www.care-statement.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cb\u003e)\u0026rdquo;\u003c/b\u003e\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eCASE 1\u003c/h2\u003e\n \u003cp\u003eA 2-year-old girl was admitted with a 9-month history of persistent fecal occult blood positivity and progressive anemia, consistent with chronic obscure gastrointestinal bleeding. During this period, she experienced intermittent dark stools without hematemesis, abdominal pain, fever, or other systemic symptoms. Her anemia gradually worsened and required repeated hospital evaluations and transfusion support.\u003c/p\u003e\n \u003cp\u003eThe patient had a complex neonatal history. Shortly after birth, she underwent abdominal surgery for multiple congenital anomalies, including omphalocele, jejunal cystic dilatation, intestinal malrotation, and congenital absence of the gallbladder. Surgical management included resection of abnormal jejunum with primary anastomosis and Ladd\u0026rsquo;s procedure. She also had congenital heart disease (atrial septal defect and patent ductus arteriosus). Postoperative recovery during infancy was satisfactory.\u003c/p\u003e\n \u003cp\u003eApproximately nine months before the current admission, persistent fecal occult blood positivity was noted during outpatient follow-up, accompanied by progressive pallor. Laboratory evaluation confirmed severe chronic blood loss anemia, with a hemoglobin nadir of 65 g/L (reference 110\u0026ndash;140 g/L) and red blood cell count of 2.36 \u0026times;10\u0026sup1;\u0026sup2;/L (reference 3.8\u0026ndash;5.2 \u0026times;10\u0026sup1;\u0026sup2;/L). On admission, hemoglobin remained markedly reduced at 72 g/L and increased only to 83\u0026ndash;90 g/L following transfusion support, indicating ongoing occult bleeding. Platelet count was 277 \u0026times;10⁹/L (reference 150\u0026ndash;400 \u0026times;10⁹/L), and white blood cell count was within normal range (reference 5.0\u0026ndash;12.0 \u0026times;10⁹/L). Coagulation parameters were preserved, including prothrombin time 13.6 s (reference 11\u0026ndash;14 s), fibrinogen 2.31 g/L (reference 2.0\u0026ndash;4.0 g/L), and D-dimer 0.26 \u0026micro;g/mL (reference\u0026thinsp;\u0026lt;\u0026thinsp;0.5 \u0026micro;g/mL).\u003c/p\u003e\n \u003cp\u003ePhysical examination demonstrated marked pallor with stable vital signs. Abdominal examination was unremarkable aside from a well-healed surgical scar. Imaging studies revealed postoperative changes in the small bowel, including segmental wall thickening and localized dilatation. Previous upper and lower endoscopy demonstrated nonspecific inflammatory findings (chronic gastritis, duodenitis, and colitis) without identification of a bleeding source. Nuclear medicine SPECT imaging showed tracer retention in the right upper abdomen, suggesting a small-bowel origin; however, the bleeding focus remained unidentified.\u003c/p\u003e\n \u003cp\u003eGiven persistent transfusion-dependent anemia and ongoing occult blood loss, a multidisciplinary discussion involving pediatric surgery, gastroenterology, hematology, and radiology was conducted. A small-bowel bleeding source beyond the reach of conventional endoscopy was suspected, and exploratory surgery combined with intraoperative enteroscopy was recommended.\u003c/p\u003e\n \u003cp\u003eUnder general anesthesia, intraoperative gastroscopy revealed nonspecific mucosal thickening in the distal duodenum without active bleeding (Fig. \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Exploratory laparotomy was subsequently performed. The previous jejunal anastomosis was patent, with proximal bowel dilatation noted, but no external lesions were visible.\u003c/p\u003e\n \u003cp\u003eAn enterotomy was created near the dilated jejunal segment, and intraoperative enteroscopy identified a focal submucosal hemorrhagic lesion in the descending duodenum, consistent with a Dieulafoy-type vascular abnormality and the presumed source of chronic bleeding (Fig. \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Additional small submucosal hemorrhagic spots suggestive of prior bleeding were observed in the distal small bowel.\u003c/p\u003e\n \u003cp\u003eThe lesion was marked under enteroscopic guidance to delineate the resection margin (Fig. 2A). Segmental small-bowel resection was then performed. Gross examination of the resected specimen demonstrated a focal hemorrhagic region corresponding to the identified lesion (Fig. 2B).\u003c/p\u003e\n \u003cp\u003eHistopathological examination of full-thickness specimens from the duodenum and small bowel revealed submucosal vascular malformation characterized by irregular, distorted vessels with uneven wall thickness. The duodenal specimen also demonstrated heterotopic gastric mucosa with focal hemorrhage. Mesenteric lymph nodes showed reactive hyperplasia without evidence of malignancy.\u003c/p\u003e\n \u003cp\u003ePostoperatively, the patient received supportive management in the intensive care unit, including gastric decompression, nutritional support, and acid suppression therapy. Hemoglobin levels stabilized without further significant decline. Transient postoperative vomiting associated with partial intestinal obstruction resolved with conservative treatment. Follow-up fecal occult blood tests became negative, hemoglobin remained stable without additional transfusion, and no recurrent gastrointestinal bleeding was observed during follow-up.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eCase 2\u003c/h3\u003e\n\u003cp\u003eA 2-year-10-month-old boy (weight 15.0 kg) was admitted with fever, cough, and generalized urticaria and was initially diagnosed with sepsis and acute upper respiratory tract infection.\u003c/p\u003e\n\u003cp\u003eOn admission, the child appeared pale but was hemodynamically stable. Abdominal examination showed no distension, tenderness, or palpable masses, and no external vascular malformations were identified. Laboratory evaluation demonstrated leukocytosis and elevated inflammatory markers (white blood cell count 15.22 \u0026times;10⁹/L [reference 5.0\u0026ndash;12.0 \u0026times;10⁹/L]; C-reactive protein 27.15 mg/L [reference\u0026thinsp;\u0026lt;\u0026thinsp;8 mg/L]). Hemoglobin progressively declined to 74 g/L (reference 110\u0026ndash;140 g/L), and platelet count increased to 455 \u0026times;10⁹/L (reference 150\u0026ndash;400 \u0026times;10⁹/L), consistent with reactive thrombocytosis secondary to inflammation and blood loss.\u003c/p\u003e\n\u003cp\u003eAfter stabilization of the infectious process, endoscopic evaluation was undertaken due to persistent anemia and ongoing fecal occult blood positivity. Routine upper gastrointestinal endoscopy identified a focal actively bleeding lesion in the proximal small bowel, morphologically consistent with a Dieulafoy-type submucosal vascular abnormality. Hemostasis was successfully achieved using endoscopic clipping.\u003c/p\u003e\n\u003cp\u003eFollowing the intervention, the child\u0026rsquo;s condition stabilized without procedural complications. Hemoglobin levels improved with supportive care, and no recurrent gastrointestinal bleeding was observed during the remainder of hospitalization. The patient was discharged in stable condition.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eObscure gastrointestinal bleeding in early childhood presents a significant diagnostic challenge in pediatric gastroenterology(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). While Dieulafoy lesions (DL) are rare, they have become increasingly recognized as an important cause of gastrointestinal hemorrhage(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Among the proposed mechanisms, a congenital vascular anomaly is most commonly suggested, in which an unusually large-caliber submucosal artery persists as it penetrates the gastric wall, increasing susceptibility to abrupt and severe bleeding. This hypothesis is supported by reports of DL occurring even in neonates(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo date, there is no universal consensus regarding the optimal management of DL; therefore, treatment selection is largely guided by lesion location, bleeding severity, and the availability of appropriate endoscopic or surgical expertise(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Endoscopy is considered the gold standard for diagnosis and treatment. Advances in endoscopic imaging and therapeutic techniques have improved diagnostic yield to approximately 70%, and treatment success rates for hemostasis approach 90%(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Historically, mortality associated with Dieulafoy lesions ranged from 23% to 79%, but with modern endoscopic management, it has decreased to less than 10%(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDespite these advances, a clinically important subgroup of patients continues to present with persistent bleeding and repeatedly negative routine investigations(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the primary case, the clinical course was characterized by prolonged fecal occult blood positivity, progressive transfusion-dependent anemia, and multiple nondiagnostic evaluations. This differs from more common pediatric presentations, which typically involve acute bleeding identified during early endoscopic examination. In this patient, the bleeding source was localized in the small bowel, and definitive identification was achieved only through intraoperative enteroscopy.\u003c/p\u003e \u003cp\u003eThe second institutional case contrasts with the primary case, as it involved successful identification through routine endoscopic evaluation. This illustrates the efficacy of endoscopy as the first-line diagnostic and therapeutic modality. In cases like these (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cb\u003eGroup A\u003c/b\u003e), standard endoscopic methods, such as argon plasma electrocoagulation, photocoagulation, and the use of clips or bands to close abnormal vessels, are highly effective in controlling bleeding.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eGroup A: Endoscopically localized and treated cases\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e, The cases summarized in Group A reflect the more typical pediatric presentation of Dieulafoy lesions, often found in the stomach or proximal duodenum and diagnosed through routine endoscopy. These cases align with broader evidence, showing high success rates for endoscopic hemostasis in controlling bleeding\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge (y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBleeding presentation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLesion location\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHb nadir (g/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTransfusion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eKey diagnostic modality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDefinitive therapy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKostopoulou (2020)(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHematemesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomach\u0026mdash;body\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEndoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eClip\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRibeiro (2024)(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHematemesis with melena and syncope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomach\u0026mdash;fundus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEndoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eClip+Injection\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmura (2016)(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMassive hematemesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomach\u0026mdash;lower body\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEndoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eClip\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiu (2022)(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMassive hematemesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomach\u0026mdash;fundus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEmergency gastroscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eClip\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChen (2022)(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMassive hematemesis and melena\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomach\u0026mdash;body (posterior wall)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.8\u0026rarr;6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGastroscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eClip+Thermal/APC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDi Nardo (2020)(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHematemsis\u0026thinsp;+\u0026thinsp;melena with worsening anemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomach\u0026mdash;body\u0026ndash;fundus junction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBand\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDi Nardo (2020)(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSudden massive hematemesis\u0026thinsp;+\u0026thinsp;melena; shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomach\u0026mdash;lesser curvature (near antrum)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eClip\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHowever, multiple endoscopies may be necessary to detect the bleeding source, with up to 6% of patients requiring three or more procedures(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The source may remain undetected because lesions are small, subtle, intermittently bleeding, or anatomically inaccessible (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Push enteroscopy, an extension of upper gastrointestinal endoscopy, can help assess the small intestine up to 150 cm from the pylorus, offering deeper evaluation when conventional endoscopy is insufficient.(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWhen endoscopy fails, angiography is a valuable alternative, particularly for lower gastrointestinal lesions.(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) Angiographic findings often show extravasation of contrast from an eroded artery, which may appear normal, tortuous, or ectatic. Angiography also serves as a second-line treatment ( Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003eGroup B\u003c/b\u003e), allowing embolization to stop bleeding when endoscopic methods fail.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eGroup B: Difficult-to-localize / occult or advanced-diagnostic cases\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of pediatric Dieulafoy-type lesions (DL) presenting with chronic or obscure gastrointestinal bleeding. Unlike classical presentations, which involve acute hematemesis or melena with rapid endoscopic localization, these cases are characterized by prolonged anemia, recurrent transfusion requirements, and repeated negative initial investigations. Lesions are often located in the small bowel or other anatomically less accessible regions, contributing to diagnostic delays. Multiple endoscopic evaluations, advanced imaging techniques, angiography, and, in some cases, surgical exploration or intraoperative enteroscopy were required to identify the bleeding source.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge (y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBleeding presentation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLesion location\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHb nadir (g/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTransfusion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eKey diagnostic modality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFailed diagnostic modality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDefinitive therapy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShang (2015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHematemesis\u0026thinsp;+\u0026thinsp;melena\u0026thinsp;+\u0026thinsp;dizziness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDuodenum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eangiography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eEmergent gastroscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eInjection\u0026thinsp;+\u0026thinsp;Embolization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShibutani (2011)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMassive hematochezia with syncope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIleum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eintraoperative fluoroscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eEGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSurgery\u0026thinsp;+\u0026thinsp;Embolization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlomari (2013)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMelena\u0026thinsp;+\u0026thinsp;syncope\u0026thinsp;+\u0026thinsp;fatigue\u0026thinsp;+\u0026thinsp;nausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDuodenum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAngiography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ecapsule endoscopy +push-enteroscopy+ intra-operative pan-enteroscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEmbolization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJurić‑Kavelj (2021)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRecurrent hematemesis\u0026thinsp;+\u0026thinsp;hemorrhagic shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEndoscopy \u0026rarr; surgery confirmation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003epush enteroscope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eClip +Injection\u0026thinsp;+\u0026thinsp;laparotomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIwamoto (2021)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMelena\u0026thinsp;+\u0026thinsp;presyncope\u0026thinsp;+\u0026thinsp;convulsions \u0026rarr; hemorrhagic shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIleal anastomosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT\u0026thinsp;+\u0026thinsp;endoscopy\u0026thinsp;+\u0026thinsp;intraoperative identification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026mdash; + Surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoreira-Pinto (2009)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHematochezia\u0026thinsp;+\u0026thinsp;syncope \u0026rarr; hemorrhagic shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIleum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003elaparotomy diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ecolonoscopy+ upper digestive endoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSalakos (2015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMassive hematemesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003esurgical identification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMultiple Endoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEndoscopic therapy\u0026thinsp;+\u0026thinsp;Surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJean (2023)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5-day history melena, fatigue, weakness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTransverse colon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ecolonoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ecapsule endoscopy+ angiography +\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eInjection+ thermocoagulation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhile surgical resection was once the first-line treatment for Dieulafoy lesions, it is now reserved as a last resort, used in about 5% of cases where endoscopy or angiography fails to control the bleeding(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In such cases, laparotomy or laparoscopy, combined with intraoperative endoscopy, may serve as both a diagnostic and therapeutic modality (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003eGroup B\u003c/b\u003e), Intra-operative enteroscopy enables direct evaluation of the small intestine with a diagnostic yield of 70\u0026ndash;100% in patients with obscure GI bleeding(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This approach allows real-time assessment of the bowel, guiding surgical intervention and improving the likelihood of lesion localization. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) However, even intraoperative enteroscopy is not invariably definitive, as lesions may remain elusive due to intermittent hemorrhage or subtle mucosal findings. In some reports, extensive investigations\u0026mdash;including capsule endoscopy, push enteroscopy, exploratory laparotomy, and intraoperative pan-enteroscopy failed to identify a specific bleeding source, ultimately necessitating angiography and embolization for localization and treatment(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFrom a clinical perspective, this study highlights a practical diagnostic pathway. In children with chronic unexplained anemia and ongoing occult gastrointestinal bleeding, repeated negative endoscopic findings should not lead to premature diagnostic closure. When bleeding persists and transfusion requirements continue, intraoperative enteroscopy may serve as both a diagnostic and therapeutic modality, enabling direct visualization of lesions that cannot be detected through nonoperative techniques.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e \u003cp\u003eThis case reports complies with all ethical guidelines. Ethical approval was not required for this study as per institutional policies, but informed consent was obtained from the patient\u0026rsquo;s guardians to share their anonymized medical information.\u003c/p\u003e \u003ch2\u003eClinical trial number:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003ch2\u003eConsent for Publication\u003c/h2\u003e \u003cp\u003eWritten informed consent for publication of this case report and any accompanying images was obtained from the patient\u0026rsquo;s guardians.\u003c/p\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was supported by the Zhejiang Medical and Health Project (2021PY014) and the Basic Public Welfare Research Program of Zhejiang Province (LGF21H040009).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eF.M. (Fredy Makele): Conceptualized the study, collected clinical data, and drafted the manuscript.Y.Y. (Yi Yang) and W.Q.Z. (Wenqiang Zhang): Conducted the literature review and contributed to drafting and revising the manuscript.Y.C.Z. (Yuchen Zhang), J.Z. (Jin Zhe), and Z.X.W. (Zhouxu Wang): Reviewed and revised the manuscript for important intellectual content and contributed to preparation of the discussion.L.B.Z.* (Libin Zhu): Corresponding author; supervised the study, provided critical analysis, and contributed substantially to the final manuscript revisions.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAvailability of Data and Materials\u003c/h2\u003e \u003cp\u003eThe dataset presented in this case report is available on request from the corresponding author during submission or after publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMorowitz MJ, Markowitz R, Kamath BM, von Allmen D. Dieulafoy\u0026rsquo;s lesion and segmental dilatation of the small bowel: an uncommon cause of gastrointestinal bleeding. 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PubMed PMID: 17102892.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Dieulafoy lesion, occult gastrointestinal bleeding, intraoperative enteroscopy, pediatric anemia, small bowel","lastPublishedDoi":"10.21203/rs.3.rs-8929921/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8929921/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003cbr\u003e\nDieulafoy-type vascular lesions of the small bowel are rare but important causes of gastrointestinal bleeding in children. Localization is particularly difficult in cases presenting with chronic occult bleeding and progressive anemia when conventional endoscopy and imaging fail to identify the source.\u003c/p\u003e\n\u003cp\u003eCase presentation\u003cbr\u003e\nWe report a toddler girl with a 9-month history of persistent fecal occult blood positivity and worsening anemia requiring repeated transfusions. A broad diagnostic work-up was undertaken, including upper and lower endoscopy, imaging studies, and nuclear medicine investigations, but none of these examinations identified a definite bleeding source. Given the ongoing occult blood loss and continued clinical deterioration, exploratory surgery with intraoperative enteroscopy was performed. This revealed multiple submucosal vascular lesions with focal hemorrhagic changes involving the duodenum and small intestine. Histopathological analysis confirmed a vascular malformation associated with heterotopic gastric mucosa. The patient recovered well after surgery, with normalization of hemoglobin levels and disappearance of fecal occult blood. A second institutional pediatric case is also included to highlight the contrasting diagnostic role of routine endoscopy. In addition, we reviewed previously published pediatric cases of occult and difficult-to-localize Dieulafoy-type lesions for comparison.\u003c/p\u003e\n\u003cp\u003eConclusion\u003cbr\u003e\nIn young children with chronic obscure gastrointestinal bleeding and negative routine investigations, small-bowel vascular lesions should be considered. When conventional endoscopic approaches fail, intraoperative enteroscopy can be a decisive diagnostic tool for identifying otherwise occult lesions and guiding management.\u003c/p\u003e","manuscriptTitle":"Intraoperative Enteroscopy After Repeated Negative Endoscopy for a Pediatric Small- Bowel Dieulafoy-Type Lesion: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-07 16:54:57","doi":"10.21203/rs.3.rs-8929921/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-22T19:11:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"333464669801051207622397471235603896182","date":"2026-04-22T19:05:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-22T18:29:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-23T06:12:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-21T09:06:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-21T09:05:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2026-02-21T02:01:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e8c7c784-af24-4cb5-9986-3371d8d74e9c","owner":[],"postedDate":"May 7th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T16:54:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-07 16:54:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8929921","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8929921","identity":"rs-8929921","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}