What is the significance of the tests ordered in making the diagnosis of Dieulafoy's lesion?
1. Dieulafoy's lesion (DL) is a rare and potentially life-threatening disease [1], accounting for 3.5% of overall gastrointestinal bleeding and an overall mortality rate ranging from 23 to 79% [2,3]. DL constitutes 15% and 1% of overall Dieulafoy's bleeding in the duodenum and jejunum, respectively [2].
2. Jejunal DL continues to be a diagnostic and therapeutic challenge depending upon the time interval between initial presentation and diagnostic modality, navigation of the jejunum, intermittent and indolent course of hemorrhage, and skillset of the doctor involved in device-assisted endoscopy, as well as other factors. Although the standard diagnostic and therapeutic modalities remain elusive, performing device-assisted enteroscopy with hemostasis may be the first priority rather than radiographic or angiographic modalities in patients without hemodynamic instability [8,9].

What are the typical features seen in this patient that are helpful in making the diagnosis of Dieulafoy's lesion?
Small bowel bleeding due to DL usually reveals concealed and intermittent gastrointestinal bleeding with an absence of surrounding mucosal ulceration5. Endoscopic criteria for the diagnosis of DL consists of the presence of spurting or pulsatile bleeding from a small mucosal defect, protruding vessels with or without active bleeding, or fresh bleeding clots with a small adherence to mucosal defects surrounded by the normal appearance of mucosa5,6. The epidemiology of DL-related small bowel bleeding varies greatly within the available literature consisting of case reports and case series [2,5,6]. Additionally, gastrointestinal bleeding caused by DL is usually encountered in the stomach (72%), followed by the duodenum (15%), esophagus (8%), colon (2%), and rectum (2%).

Patient Care (Case Correlation to ACGME Core Competency Requirements)
1. Understand and recognize the clinical presentation of small bowel bleeding.
2. Obtain an appropriate history to determine if a patient might have small bowel bleeding.
3. Determine who should be referred to a gastroenterologist for evaluation of small bowel bleeding.
4. Determine the appropriate testing used to support the diagnosis of small bowel bleeding.

Medical Knowledge (Case Correlation to ACGME Core Competency Requirements)
1. Understand the evaluation of small bowel bleeding.
2. Interpret the results of endoscopic and radiological testing
3. Recognize the manifestations of small bowel bleeding.

Practice-Based Learning and Improvement (Case Correlation to ACGME Core Competency Requirements)
1. Set goals for studying about small bowel bleeding clinical manifestations, and treatment options.
2. Demonstrate the ability to review and interpret literature relevant to the care of patients with small bowel bleeding.

Practice-Based Learning and Improvement (Case Correlation to ACGME Core Competency Requirements)
1. Set goals for studying about small bowel bleeding clinical manifestations, and treatment options.
2. Demonstrate the ability to review and interpret literature relevant to the care of patients with small bowel bleeding.

Interpersonal and Communication Skills (Case Correlation to ACGME Core Competency Requirements)
1. Discuss the results of endoscopic and radiological testing with a patient.
2. Discuss the diagnosis of small bowel bleeding with a patient.
3. Discuss the need for appropriate follow up and monitoring with a patient
4. Comprehensively explain different treatment options based on disease manifestations

Professionalism (Case Correlation to ACGME Core Competency Requirements)
1. Recognize the importance of patient confidentiality and privacy.
2. Understand the need to provide supportive care.
3. Encourage patients to ask questions regarding their disease and empower them to be active participants in their care.
4. Provide adequate time and accessibility to address patient concerns.
5. Demonstrate an understanding of informed consent with regard to therapeutic options in the treatment of small bowel bleeding.

System-Based Practice (Case Correlation to ACGME Core Competency Requirements)
1. Create a team approach to manage patients with small bowel bleeding engaging physicians from multiple disciplines.
2. Identify barriers to access and delivery of care for patients with complex, multi-system diseases.
3. Learn about resources available to improve delivery of care and patient support.
4. Identify the ways in which one can be a patient advocate, including obtaining prior authorization for medications, treatments, and diagnostic tests.
5. Demonstrate an awareness of the economic implications of a diagnosis of small bowel bleeding for the patient, and the potential impact on healthcare systems caring for patients with chronic conditions.