DOI: https://doi.org/10.36347/sjmcr.2026.v14i05.054

Pages: 1097-1100

Dieulafoy lesions are an uncommon cause of acute gastrointestinal bleeding and are typically located in the proximal stomach. Localization within a hiatal hernia sac is exceptionally rare and may lead to diagnostic delay. We report a case of massive upper gastrointestinal bleeding originating from a Dieulafoy lesion located at the neck of a hiatal hernia, initially missed during endoscopic evaluation. A 56-year-old North African woman undergoing evaluation for operable cholangiocarcinoma presented with acute massive upper gastrointestinal bleeding manifested by abundant hematemesis. On admission, the patient was hemodynamically stable but symptomatic, prompting urgent endoscopic evaluation. Initial upper endoscopy was negative despite ongoing bleeding. A second emergency endoscopy performed revealed diffuse oozing within a confirmed hiatal hernia. After extensive lavage, contact between the endoscope and a small mucosal defect triggered pulsatile arterial bleeding consistent with a Dieulafoy lesion located at the hernia neck. Immediate hemostasis was achieved using a standard through-the-scope hemostatic clip. No rebleeding occurred during hospitalization. This case highlights the importance of meticulous inspection of the hiatal hernia sac during emergency endoscopy, particularly after an initially negative examination, as occult Dieulafoy lesions may cause life-threatening bleeding