dieulafoy 's lesion was first described by gallard in 1884 . originally named the exulceratio simplex , it was named after the french surgeon georges dieulafoy 14 years after its initial discovery cirsoid aneurysm , the dieulafoy 's lesion consists of a dilated submucosal vessel that causes significant bleeding when it erodes the overlying epithelium , without primary ulcer leading to its exposure . the lesion is most commonly located in the lesser curvature of the stomach , with infrequent occurrences in the small bowel and the colon . the esophagus is an exceedingly rare location for this lesion , with few case reports published in the literature . the pathophysiology of the lesion is believed to be congenital in nature , with rare reports of its occurrence in neonates and young infants . in most published series , however , particular comorbidities appear to have very strong correlation with the dieulafoy lesion , most notably ; cardiovascular disease , hypertension , chronic renal disease , diabetes mellitus and excessive alcohol abuse . collectively , these comorbidities have been associated with almost 90% of patients having this condition . a 55-year - old male with history of intellectual disability presented to our institutions emergency room after being found by his father to be obtunded and unresponsive . upon presentation to the patient 's room , the surgical team noted that the patient was vomiting large volumes of bright red blood , and was significantly tachycardic to the 140s and hypotensive . upon questioning , patient 's father reported that he is usually communicative , and that he had now been unresponsive for many hours . past medical history : diabetes mellitus type ii , hypertension , hyperlipidemia , alcohol and polysubstance abuse . on examination , the abdomen was soft , not distended , no rebound ; with large amounts of blood noted around the mouth and staining the patients clothes . the patient was emergently resuscitated in the emergency department with placement of large bore intravenous access and initiation of the institution 's massive transfusion protocol . he was subsequently transferred to the surgical intensive care unit where he continued to have copious amounts of hematamesis . the patient was intubated for airway protection , and emergent esophagogastroduodenoscopy ( egd ) was performed at the bedside . egd revealed active pulsatile bleeding from an exposed vessel in the distal portion of the esophagus without underlying ulceration ( fig . attempts were made at epinephrine injection sclerosis ; however , bleeding was finally amended with resolution clip placement ( fig . following establishment of hemostasis , the patient was maintained on ppi drip in the sicu and progressively stabilized . one of the more rare causes of upper gastrointestinal ( gi ) bleeding is  dieulafoy 's lesion , which is responsible for ~1.5% of acute upper gi bleeding . paul georges dieulafoy named the lesion after he described a series of 10 patients who  presented with massive hematemesis due to a bleeding gastric vessel without associated ulceration in 1897 . while initially only described in the stomach , dieulafoy lesions have presented at several other anatomic locations . of note , 7590% occur in the proximal stomach , though small bowel , colon , ano - rectal and extra - intestinal lesions have also been described . a dieulafoy 's lesion is a congenital arteriovenous malformation characterized by an ectatic submucosal artery ; if eroded it may lead to pulsatile bleeding . anatomically , arteries should narrow as they approach the mucosa , but a dieulafoy artery maintains a persistent caliber through the submucosa , leading to the eponym of  caliber - persistent artery . the mechanisms causing the tortuosity and the persistence of the large - sized submucosal arteries remain unknown , though bleeding is thought to be secondary to erosion caused by the pulsations of the artery and not by a primary ulceration of the mucosa . the lesion appears as a stream of arterial blood emanating from what appears to be grossly normal mucosa , though a minute defect should be present . up to 71% of initial endoscopies are diagnostic only if there is active hemorrhage of at least 0.5  ml / min . however , in 6% of patients , the intermittent nature of the bleeding often requires multiple endoscopies to establish a definitive diagnosis like in our patient . due to the subtlety of the lesion , endoscopic criteria have been established for diagnosis of a dieulafoy lesion ; endoscopic visual criteria that must be met include ( i ) active arterial spurting or oozing from a small ( <3  mm ) defect in the mucosa , ( ii ) visualization of a vessel protruding from a slight defect or normal mucosa and/or ( iii ) a fresh blood clot adherent to a defect of normal mucosa as described by dieulafoy . with the advent of endoscopy , multiple modalities may be used for treatment and since 1986 this has become the mainstay for treating these lesions . the endoscopist may choose to band the lesion , use an endoscopic clip , as we had in this patient , use thermocoagulation or inject epinephrine into the lesion . if endoscopy fails to diagnose the lesion , angiography may be employed and the lesion may be embolized . if minimally invasive approaches fail , surgical intervention may be warranted if the patient continues in extremis . surgery is reserved as a last resort when the location of the lesion is known and previously attempted therapies have failed . intraoperatively , the lesion may be amendable to oversewing or a wide local excision may be performed , which is preferable given that simple oversewing has shown to be associated with a greater incidence of recurrent bleeding .
dieulafoy 's lesion , a dilated aberrant submucosal vessel which erodes the overlying epithelium , is a relatively rare but potentially fatal cause of gastrointestinal ( gl ) bleeding . 
 the esophagus is a very rare location for the lesion . here 
 we present a case of massive upper gi bleeding , secondary to this remarkably rare occurrence , which was amendable to endoscopic intervention .