Bleeding Dieulafoy’s-like lesions of the gut identified by capsule endoscopy

Diagnosis and therapeutic strategies for small bowel vascular lesions

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.

A single-center United States experience with bleeding Dieulafoy lesions of the small bowel: diagnosis and treatment with single-balloon enteroscopy

INTRODUCTION

A Dieulafoy lesion (DL) of the small bowel can cause severe gastrointestinal bleeding, and presents a difficult clinical setting for endoscopists. Limited data exists on the therapeutic yield of treating DLs of the small bowel using single-balloon enteroscopy (SBE).

METHODS

Data were collected from Tampa General Hospital a 1 018-bed teaching hospital affiliated with University of South Florida in Tampa, Florida. Patients were selected from a database of patients that underwent SBE from January 2010 - August 2013.

RESULTS

Eight patients were found to have DL an incidence of 2.6 % of 309 SBE performed for obscure gastrointestinal bleeding. 7/8 were identified in the jejunum, with one found in the duodenum. The mean age of patients with DL was 71.5 years old. 6/8 patients were on some form of anticoagulant/antiplatelet agent. The primary modality of therapy employed was electrocautery, multipolar electrocoagulation in seven patients and APC (argon plasma coagulation) in one patient. In three patients, electrocoagulation was unsuccessful and hemostasis was achieved with clip placement. Three patients required repeat SBE with one found to have rebleeding from a failed clip with hemostasis achieved upon reapplication of one clip.

CONCLUSION

In our United States' experience, SBE offers a reasonable therapeutic approach to treat DL of the small bowel with low rates of rebleeding, no adverse events, and no patient requiring surgery.

The Dieulafoy's Lesion: An Update on Evaluation, Diagnosis, and Management

Dieulafoy's lesion (DL) is a persistently wide caliber artery that is observed more frequently at the fifth decade of life in the male population with multiple comorbidities. There are a variety of endoscopic therapies that have been used to treat DL; however, there are no clear guidelines on the best treatment modality. This article systematically reviews the diagnosis, the most commonly reported therapies of DL, and offers a suggested algorithm based upon efficacy of treatment such as initial hemostasis, rebleeding rates, and mortality.

Different roles of capsule endoscopy and double-balloon enteroscopy in obscure small intestinal diseases

AIM: To compare the roles of capsule endoscopy (CE) and double-balloon enteroscopy (DBE) in the diagnosis of obscure small bowel diseases.

METHODS: From June 2009 to December 2014, 88 patients were included in this study; the patients had undergone gastroscopy, colonoscopy, radiological small intestinal barium meal, abdominal computed tomography or magnetic resonance imaging scan and mesenteric angiography, but their diagnoses were still unclear. The patients with gastrointestinal obstructions, fistulas, strictures, or cardiac pacemakers, as well as pregnant women, and individuals who could not accept the capsule-retention or capsule-removal surgery were excluded. Patients with heart, lung and other vital organ failure diseases were also excluded. Everyone involved in this study had undergone CE and DBE. The results were divided into: (1) the definite diagnosis (the diagnosis was confirmed at least by one of the biopsy, surgery, pathology or the drug treatment effects with follow-up for at least 3 mo); (2) the possible diagnosis (a possible diagnosis was suggested by CE or DBE, but not confirmed by the biopsy, surgery or follow-up drug treatment effects); and (3) the unclear diagnosis (no exact causes were provided by CE and DBE for the disease). The detection rate and the diagnostic yield of the two methods were compared. The difference in the etiologies between CE and DBE was estimated, and the different possible etiologies caused by the age groups were also investigated.

RESULTS: CE exhibited a better trend than DBE for diagnosing scattered small ulcers (P = 0.242, Fisher’s test), and small vascular malformations (χ² = 1.810, P = 0.179, Pearson χ² test), but with no significant differences, possible due to few cases. However, DBE was better than CE for larger tumors (P = 0.018, Fisher’s test) and for diverticular lesions with bleeding ulcers (P = 0.005, Fisher’s test). All three hemangioma cases diagnosed by DBE in this study (including sponge hemangioma, venous hemangioma, and hemangioma with hamartoma lesions) were all confirmed by biopsy. Two parasite cases were found by CE, but were negative by DBE. This study revealed no obvious differences in the detection rates (DR) of CE (60.0%, 53/88) and DBE (59.1%, 52/88). However, the etiological diagnostic yield (DY) difference was apparent. The CE diagnostic yield was 42.0% (37/88), and the DBE diagnostic yield was 51.1% (45/88). Furthermore, there were differences among the age groups (χ² = 22.146, P = 0.008, Kruskal Wallis Test). Small intestinal cancer (5/6 cases), vascular malformations (22/29 cases), and active bleeding (3/4 cases) appeared more commonly in the patients over 50 years old, but diverticula with bleeding ulcers were usually found in the 15-25-year group (4/7cases). The over-25-year group accounted for the stromal tumors (10/12 cases).

CONCLUSION: CE and DBE each have their own advantages and disadvantages. The appropriate choice depends on the patient’s age, tolerance, and clinical manifestations. Sometimes CE followed by DBE is necessary.