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Kavitt RT, Gralnek IM. Ideal strategy for nonvariceal upper gastrointestinal bleeding. Curr Opin Gastroenterol 2024:00001574-990000000-00161. [PMID: 38967918 DOI: 10.1097/mog.0000000000001043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
PURPOSE OF REVIEW Over 300 000 hospital admissions in the United States each year are due to patients with upper gastrointestinal (GI) bleeding (UGIB). Common etiologies of nonvariceal UGIB include peptic ulcers, mucosal erosions of the esophagus, stomach or duodenum, Mallory-Weiss tears, Dieulafoy lesions, upper GI tract malignancy, or other etiology. RECENT FINDINGS Peptic ulcers classified as Forrest Ia, Ib, or IIa require endoscopic hemostasis, while IIb ulcers may be considered for endoscopic clot removal with endoscopic treatment of any underlying major stigmata. Endoscopic hemostasis for ulcers classified as Forrest IIc or III is not advised due to the low risk of recurrent bleeding. Endoscopic hemostasis in ulcer bleeding can be achieved using injection, thermal, and/or mechanical modalities. SUMMARY This review focuses on the currently recommended endoscopic therapies of patients presenting with acute nonvariceal upper gastrointestinal hemorrhage.
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Affiliation(s)
- Robert T Kavitt
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, Illinois, USA
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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2
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Aabdi B, Kharrasse G, Zazour A, Koulali H, Elmqaddem O, Zahi I. Clinical, endoscopic and therapeutic features of bleeding Dieulafoy's lesions: case series and literature review. BMJ Open Gastroenterol 2024; 11:e001299. [PMID: 38789268 PMCID: PMC11129027 DOI: 10.1136/bmjgast-2023-001299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 04/21/2024] [Indexed: 05/26/2024] Open
Abstract
OBJECTIVE Dieulafoy's lesions (DLs) are a rare but potentially life-threatening source of gastrointestinal (GI) haemorrhage. They are responsible for roughly 1%-6.5% of all cases of acute non-variceal GI bleeding.Here, we describe retrospectively the clinical and endoscopic features, review the short-term and long-term outcomes of endoscopic management of bleeding DLs and we identify rate and risk factors, of recurrence and mortality in our endoscopic unit. DESIGN Data were collected from patients presenting with GI haemorrhagic secondary to DLs between January 2018 and August 2023. Patients' medical records as well as endoscopic databases were retrospectively reviewed. Demographic data, risk factors, bleeding site, outcomes of endoscopy techniques, recurrence and mortality rate were taken into account. RESULTS Among 1170 cases of GI bleeding, we identified only seven cases involving DLs. Median age was 74 years, with a male-to-female ratio of 2.5. 75% of patients had significant comorbidities, mainly cardiovascular diseases. Only anticoagulant and antiplatelet agents were significantly associated with DLs. All patients were presented with GI bleeding as their initial symptom. The initial endoscopy led to a diagnosis in 85% of the cases. Initial haemostasis was obtained in all patients treated endoscopically. Nevertheless, the study revealed early recurrence in two out of three patients treated solely with epinephrine injection or argon plasma coagulation. In contrast, one of three patients who received combined therapy, experienced late recurrence (average follow-up of 1 year). Pathological diagnosis was necessary in one case. One patient (14%) died of haemorrhagic shock. Average length of hospital stay was 3 days. CONCLUSION Although rare, DLs may be responsible for active, recurrent and unexplained GI bleeding. Thanks to the emergence of endoscopic therapies, the recurrence rate has decreased and the prognosis has highly improved. Therefore, the endoscopic approach remains the first choice to manage bleeding DLs.
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Affiliation(s)
- Basma Aabdi
- Gastroenterology, Mohammed VI University Hospital Oujda, Morocco, Oujda, Morocco
| | - Ghizlane Kharrasse
- Gastroenterology, Mohammed VI University Hospital Oujda, Morocco, Oujda, Morocco
| | - Abdelkrim Zazour
- Digestive Disease Research Laboratory (LARMAD), Mohammed I University, Faculty of Medicine and Pharmacy, Oujda, Morocco, Oujda, Morocco
| | - Hajar Koulali
- Digestive Disease Research Laboratory (LARMAD), Mohammed I University, Faculty of Medicine and Pharmacy, Oujda, Morocco, Oujda, Morocco
| | - Ouiam Elmqaddem
- Digestive Disease Research Laboratory (LARMAD), Mohammed I University, Faculty of Medicine and Pharmacy, Oujda, Morocco, Oujda, Morocco
| | - Ismaili Zahi
- Gastroenterology, Mohammed VI University Hospital Oujda, Morocco, Oujda, Morocco
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Postoll-Downs MA, Ozguc F, Vasudevan J, Stawinski PM, Wright R. Breaking Patterns: A Case of Dieulafoy Lesion in a Young Patient Without Comorbid Conditions. Cureus 2024; 16:e60513. [PMID: 38883023 PMCID: PMC11180519 DOI: 10.7759/cureus.60513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/18/2024] Open
Abstract
A Dieulafoy lesion is an abnormal artery located in the gastric submucosa that represents a rare cause of upper gastrointestinal bleeding. These lesions typically present as massive hemorrhages in older patients, with multiple medical comorbidities. The lesions are diagnosed with endoscopy and treated with hemostasis by clip placement or coagulation. This case report is that of a rare presentation of this rare condition in a younger 18-year-old patient with no medical comorbidities. He presented with hematemesis, melena, and syncope in the setting of ibuprofen self-treatment for a recent upper viral illness. This medication use is a proposed inciting factor for the bleeding lesion, though he had a history of a splenic artery embolization following a remote motor vehicle accident, which could represent a mechanism for a rare acquired lesion. A gastroenterologist was consulted and assisted in the diagnosis and management of this patient. His lesion was identified and treated within 24 hours of his presentation.
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Affiliation(s)
- Melissa A Postoll-Downs
- Internal Medicine, San Antonio Uniformed Services Health Education Consortium, San Antonio, USA
| | - Fatma Ozguc
- Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Jaya Vasudevan
- Gastroenterology, The University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Peter M Stawinski
- Gastroenterology, The University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Randy Wright
- Gastroenterology, The University of Texas Health Science Center at San Antonio, San Antonio, USA
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Zazour A, Belkhayat C, Bennani A, Bouziane M, Kharrasse G, Ismaili Z. Two cases of Dieulafoy's lesion in unusual sites: A rare case reports of gastrointestinal bleeding. Int J Surg Case Rep 2024; 117:109562. [PMID: 38518467 PMCID: PMC10972791 DOI: 10.1016/j.ijscr.2024.109562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/15/2024] [Accepted: 03/17/2024] [Indexed: 03/24/2024] Open
Abstract
INTRODUCTION Dieulafoy's lesion (DL) is a vascular malformation that can lead to massive gastrointestinal bleeding. It's usually found in the stomach. However, DL's occurrence in atypical sites such as the small bowel and colon is exceptionally rare, posing significant management challenges. CASE PRESENTATION In this report, we present two cases of DL occurring in uncommon sites, each managed with distinct approaches. Case 1 is a 50-year-old man admitted to the emergency department due to massive GI bleeding and hemodynamic instability. The diagnosis of DL was established through computed tomography angiography and confirmed by histopathological examination after emergency surgery. Case 2 involves a 68-year-old woman presented with melena due to a colonic DL. This case was successfully managed through an endoscopic hemostasis approach. DISCUSSION Dieulafoy's lesions (DL) were first identified as a large submucosal artery lacking typical gastric ulcer characteristics in three of Paul Georges Dieulafoy's patients. This lesion is responsible for approximately 1-2 % of all cases of gastrointestinal bleeding. Endoscopy is the preferred method for diagnosing and managing DL lesions, especially in cases of active bleeding that is accessible. However, if endoscopic treatment or angiographic embolization fails, a surgical approach may be needed. CONCLUSION DL presents a diagnostic challenge due to its rarity and is not usually included in the differential diagnosis of gastrointestinal bleeding, particularly when occurring in unusual sites. Endoscopy is the preferred method to identify DL and a possible therapeutic approach in active bleeding. However, if endoscopy hemostasis fails, angiographic embolization or surgical intervention may be required.
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Affiliation(s)
- Abdelkrim Zazour
- Hepato-gastroenterology Department, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, University of Mohammed First, Oujda, Morocco; Laboratory of Digestive Disease Research, Faculty of Medicine and Pharmacy of Oujda, University of Mohammed First, Oujda, Morocco.
| | - Chifaa Belkhayat
- Hepato-gastroenterology Department, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, University of Mohammed First, Oujda, Morocco
| | - Amal Bennani
- Laboratory of Digestive Disease Research, Faculty of Medicine and Pharmacy of Oujda, University of Mohammed First, Oujda, Morocco; Pathology Department, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, University of Mohammed First, Oujda, Morocco
| | - Mohamed Bouziane
- General Surgery Department, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, University of Mohammed First, Oujda, Morocco
| | - Ghizlane Kharrasse
- Hepato-gastroenterology Department, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, University of Mohammed First, Oujda, Morocco; Laboratory of Digestive Disease Research, Faculty of Medicine and Pharmacy of Oujda, University of Mohammed First, Oujda, Morocco
| | - Zahi Ismaili
- Hepato-gastroenterology Department, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, University of Mohammed First, Oujda, Morocco; Laboratory of Digestive Disease Research, Faculty of Medicine and Pharmacy of Oujda, University of Mohammed First, Oujda, Morocco
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5
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Atri S, Hammami M, Ouadi Y, Sebai A, Chaker Y, Kacem M. Dieulafoy's lesion: Is there still a place for surgery? About 2 cases. Int J Surg Case Rep 2024; 114:109166. [PMID: 38113567 PMCID: PMC10772228 DOI: 10.1016/j.ijscr.2023.109166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 12/08/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION Dieulafoy's lesion, a rare but life-threatening condition accounting for a small percentage of acute gastrointestinal bleeding cases, has historically posed diagnostic and therapeutic challenges. CASE PRESENTATION In this article, we present two cases that required surgical intervention due to unsuccessful attempts with endoscopy. Case 1 involved a 40-year-old patient with a history of treated duodenal ulcers, while Case 2 featured a 74-year-old woman with no notable medical history. Both patients exhibited severe bleeding, necessitating urgent surgical procedures. The surgical approach involved wide gastrotomy, careful inspection, and successful suturing of the bleeding vessel. DISCUSSION Dieulafoy lesions, discovered by French surgeon Georges Dieulafoy in 1885, constitute 1-2 % of acute gastrointestinal bleeding cases. These anomalies involve enlarged submucosal arteries, predominantly in the stomach, but occurrences in other sites are documented. Endoscopic methods, surpassing surgical intervention, are preferred for treatment, boasting success rates over 90 %. Surgical measures become a last resort for uncontrolled bleeding, with laparoscopic surgery emerging as a minimally invasive alternative, facilitated by various intra-operative localization techniques. Laparoscopic wedge resection, in particular, exhibits lower re-bleeding rates than traditional oversewing methods, although feasibility depends on lesion location. CONCLUSION While endoscopic methods are preferred, surgery remains a vital option when bleeding persists or endoscopic intervention fails. This report highlights the significance of surgical management in selected cases of Dieulafoy's lesion.
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Affiliation(s)
| | | | | | - Amine Sebai
- Department, Hopital la Rabta, Tunis, Tunisia
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Bartnicki-Navarrete I, Garay-Ortega JA, Robles-Fernandes LF. Esophageal Dieulafoy's lesion treated with band ligation: Individualized treatment for an atypical presentation. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:446-448. [PMID: 38097436 DOI: 10.1016/j.rgmxen.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 08/09/2023] [Indexed: 01/01/2024]
Affiliation(s)
| | - J A Garay-Ortega
- Departamento de Gastroenterología, Centro Médico Nacional Siglo XXI, Mexico City, Mexico.
| | - L F Robles-Fernandes
- Departamento de Medicina Interna, Centro Médico Nacional Siglo XXI, Mexico City, Mexico
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Martínez-Ortiz CA, Alvarez-Sores ED, Lara-Orozco U, Murcio-Pérez E. Dieulafoy's lesion of the rectum: A case report. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:301-304. [PMID: 37208209 DOI: 10.1016/j.rgmxen.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/23/2023] [Indexed: 05/21/2023]
Affiliation(s)
- C A Martínez-Ortiz
- Departamento de Gastrocirugía, Hospital de Especialidades del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - E D Alvarez-Sores
- Departamento de Gastrocirugía, Hospital de Especialidades del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico.
| | - U Lara-Orozco
- Departamento de Gastrocirugía, Hospital de Especialidades del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - E Murcio-Pérez
- Departamento de Endoscopia Gastrointestinal, Hospital de Especialidades del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
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8
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Qasim A, Schmidt P, Bhatt T, Itare V, Ihimoyan A, Khaja M, Kandhi S. Dieulafoy's Lesion of the Duodenum: A Rare and Fatal Cause of Gastrointestinal Bleed. Cureus 2023; 15:e40050. [PMID: 37425531 PMCID: PMC10324985 DOI: 10.7759/cureus.40050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 07/11/2023] Open
Abstract
Dieulafoy's lesion (DL) is an unusual cause of recurrent gastrointestinal bleeding that can be fatal. It can occur in various parts of the gastrointestinal (GI) tract, most commonly located in the stomach, especially at the level of lesser curvature; however, it can occur in other parts, including the colon, esophagus, and duodenum. A duodenal Dieulafoy lesion is characterized by the presence of a larger-caliber artery that protrudes through the GI mucosa and can lead to massive hemorrhage. The exact cause of DL is yet to be determined. Clinical presentation includes painless upper GI bleeding, including melena, hematochezia, and hematemesis, or rarely iron deficiency anemia (IDA); however, most of the patients are asymptomatic. Some patients also have non-gastrointestinal comorbidities such as hypertension, diabetes, and chronic kidney disease (CKD). The diagnosis is established by esophagogastroduodenoscopy (EGD), which includes the presence of micro pulsatile streaming from a mucosal defect, the appearance of a fresh, densely adherent clot with a narrow point of attachment to a minute mucosal defect, and the visualization of a protruding vessel with or without bleeding. Initial EGD can be non-diagnostic due to the relatively small size of the lesion. Other diagnostic modalities include endoscopic ultrasound and mesenteric angiography. The treatment of duodenal DL includes thermal electrocoagulation, local epinephrine injection, sclerotherapy, banding, and hemoclipping. We present here a case of a 71-year-old female who had a history of severe IDA requiring multiple blood transfusions and intravenous iron in the past and was found to have duodenal DL.
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Affiliation(s)
- Abeer Qasim
- Internal Medicine, BronxCare Health System, Bronx, USA
| | | | | | - Vikram Itare
- Internal Medicine, BronxCare Health System, Bronx, USA
| | | | | | - Sameer Kandhi
- Internal Medicine, BronxCare Health System, Bronx, USA
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9
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Garg H, Padia G, Raj A, Khanna S, Vohra S. Over-the-scope clip for Dieulafoy's lesion: A new 'normal' technique. Indian J Gastroenterol 2023; 42:438-439. [PMID: 37247178 DOI: 10.1007/s12664-023-01364-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Hitendra Garg
- Department of Gastroenterology and Hepatology, Indraprastha Apollo Hospital, New Delhi, 110 076, India.
| | - Gaurav Padia
- Department of Gastroenterology and Hepatology, Indraprastha Apollo Hospital, New Delhi, 110 076, India
| | - Anupam Raj
- Department of Anesthesia, Indraprastha Apollo Hospital, New Delhi, 110 076, India
| | - Sudeep Khanna
- Department of Gastroenterology and Hepatology, Indraprastha Apollo Hospital, New Delhi, 110 076, India
| | - Sandeep Vohra
- Department of Radiology, Indraprastha Apollo Hospital, New Delhi, 110 076, India
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10
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Kusnik A, Mostafa MR, Sharma RP, Chodos A. Dieulafoy Lesion: Scope it Until You Find it. Cureus 2023; 15:e36097. [PMID: 37065413 PMCID: PMC10097443 DOI: 10.7759/cureus.36097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 03/14/2023] Open
Abstract
A Dieulafoy lesion is an important consideration every gastroenterologist and internal medicine physician has to make in cases of recurrent, unidentifiable, and hemodynamically compromising gastrointestinal (GI) bleeding. A Dieulafoy lesion is an aberrant vessel that does not reduce in caliber when it extends from the submucosa to the mucosa. Damage to this artery can result in severe, intermittent arterial bleeding from tiny, difficult-to-visualize vessel stumps. Furthermore, these catastrophic bleeding episodes frequently result in hemodynamic instability and the need for transfusion of multiple blood products. As the patients presenting with Dieulafoy lesions often have concomitant cardiac and renal disease, familiarity with this condition is relevant as these patients are at risk of transfusion-related injuries. This case is unique as the Dieulafoy lesion was not visualizable in a standard location despite multiple esophagogastroduodenoscopy (EGD) and CT angiography, illustrating the difficulty of accurately managing and diagnosing this condition.
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11
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Jo SY, Noh JH, Cha B, Ahn JY, Oh SP, Seo JY, Na HK, Lee JH, Jung KW, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Clinical outcomes of Dieulafoy's lesion compared with peptic ulcer in upper gastrointestinal bleeding. J Gastroenterol Hepatol 2023. [PMID: 36740948 DOI: 10.1111/jgh.16139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 01/23/2023] [Accepted: 02/02/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Although Dieulafoy's lesion (DL) is an important cause of nonvariceal upper gastrointestinal (GI) bleeding, few studies have investigated the clinico-epidemiological outcomes due to its rarity. Here, we investigated clinical features of upper GI bleeding caused by peptic ulcer (PU) or DL and compared endoscopic treatment outcomes. METHODS Patients with upper GI bleeding resulting from PU or DL who visited emergency room between January 2013 and December 2017 were eligible. Clinical features and treatment outcomes were retrospectively investigated. RESULTS Overall, 728 patients with upper GI bleeding due to PU (n = 669) and DL (n = 59) were enrolled. The median age was 64 years (interquartile range [IQR], 56-75 years), and 74.3% were male. Endoscopic intervention was performed in 53.7% (n = 359) and 98.3% (n = 58) of the PU and DL groups, respectively (P < 0.0001). Patients were matched by sex, age, body mass index, comorbidity, and past medical history, and 190 PU and 52 DL were finally selected. The rebleeding rates within 7 (7.37% vs 17.31%, P = 0.037) and 30 (7.37% vs 26.92%, P < 0.001) days after initial endoscopy were significantly lower in the PU than in the DL group after propensity score matching. During the median follow-up period of 52 months (IQR, 34-70 months), there was no difference in overall survival rate (67.9% vs 82.7%, P = 0.518). CONCLUSIONS Although DL is a rare cause of upper GI bleeding, it requires endoscopic hemostasis more frequently and has a higher rate of rebleeding than PU even after therapeutic endoscopy. Endoscopists should pay attention and perform active endoscopic hemostasis for DL bleeding.
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Affiliation(s)
- Sang Yong Jo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Boram Cha
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Pyo Oh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun-Young Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Miyao M, Kawai C, Kotani H, Minami H, Abiru H, Hamayasu H, Yamamoto A, Tamaki K. Fatal Dieulafoy lesion with IgG4-related disease: An autopsy case report. Leg Med (Tokyo) 2022; 57:102059. [DOI: 10.1016/j.legalmed.2022.102059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/24/2022] [Accepted: 04/04/2022] [Indexed: 02/07/2023]
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13
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Inayat F, Hussain A, Yahya S, Weissman S, Sarfraz N, Faisal MS, Riaz I, Saleem S, Saif MW. Rectal Dieulafoy's lesion: a comprehensive review of patient characteristics, presentation patterns, diagnosis, management, and clinical outcomes. Transl Gastroenterol Hepatol 2022; 7:10. [PMID: 35243119 PMCID: PMC8826214 DOI: 10.21037/tgh.2020.02.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 02/10/2020] [Indexed: 08/10/2023] Open
Abstract
Dieulafoy's lesion is an abnormally large, tortuous, submucosal vessel that erodes the overlying mucosa, without primary ulceration or erosion. Although these lesions predominantly involve the stomach and upper small intestine, they are being detected with increasing frequency in the rectum. We conducted a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases for adult rectal Dieulafoy's lesion. After careful review of the search results, a total of 101 cases were identified. The data on patient characteristics, clinical features, colonoscopy findings, diagnosis, treatment, and clinical outcomes were collected and analyzed. The mean age of presentation was 66±17 years (range, 18-94 years), with 54% of cases reported in males. Clinical presentation was dominated by acute lower gastrointestinal bleeding in the form of bright-red blood per rectum 47% and hematochezia 36%, whereas 16% of patients were admitted with symptoms related to other medical conditions. Major underlying disorders were hypertension 29%, diabetes mellitus 21%, and chronic kidney disease 16%. The average number of colonoscopies required for the diagnosis of rectal Dieulafoy's lesion was 1.5±0.7. In regard to treatment, endoscopic therapy was applied in 80%, direct surgical suturing in 12%, angiographic embolization in 4%, and endoscopic therapy followed by surgical ligation was performed in 4% of patients. The endoscopic treatment was a feasible choice for rectal disease, with a primary hemostasis rate of 88%. Although the overall mortality rate was 6%, the causes of death were unrelated to this entity. This review illustrates that patients with rectal Dieulafoy's lesion can have a favorable clinical outcome. Prompt diagnosis and appropriate management are of paramount importance to prevent serious hemodynamic complications. The best therapeutic modality remains to be determined but the data presented here support the use of mechanical endoscopic methods as safe and effective.
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Affiliation(s)
| | | | - Sidra Yahya
- Fatima Jinnah Medical University, Lahore, Pakistan
| | - Simcha Weissman
- Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | | | | | - Iqra Riaz
- Einstein Medical Center, Philadelphia, PA, USA
| | - Saad Saleem
- Mercy Saint Vincent Medical Center, Toledo, OH, USA
| | - Muhammad Wasif Saif
- The Feinstein Institute of Medical Research, Manhasset, NY, USA
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Achuo-Egbe Y, Hashmi SSH, Shady A, Khan GM. A Rare Cause of Recurrent Lower Gastrointestinal Bleed: Colonic Dieulafoy’s Lesion. Cureus 2021; 13:e20384. [PMID: 35036215 PMCID: PMC8752380 DOI: 10.7759/cureus.20384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2021] [Indexed: 11/11/2022] Open
Abstract
Dieulafoy’s lesion accounts for 1%-2% of acute gastrointestinal (GI) bleeding cases, and approximately 2% of Dieulafoy’s lesions are present in the colon. We report the case of an 83-year-old female who presented with recurrent gastrointestinal bleeding from colonic Dieulafoy’s lesion located at the hepatic flexure. She initially presented four weeks prior with melena in the setting of Eliquis use for venous thrombosis, coronary artery disease, and end-stage renal disease. Upper endoscopy revealed esophagitis, gastritis, and duodenitis. Diagnostic colonoscopy and video capsule endoscopy both revealed blood in the colon without an identifiable source. During the second admission for recurrent melena with hemoglobin of 3.9 g/dL, Eliquis was discontinued, and the patient was resuscitated with three units of packed red blood cell transfusions. Repeat colonoscopy revealed a pulsating vessel with active oozing located at the hepatic flexure, consistent with a Dieulafoy’s lesion. Hemostatic endoclips and bipolar electrocautery were applied to achieve complete hemostasis. Colonic Dieulafoy’s lesions, albeit rare, should be considered in patients presenting with an acute obscure lower GI bleed. Primary hemostasis can be achieved with several endoscopic modalities including epinephrine, hemoclipping, thermocoagulation, or sclerotherapy.
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15
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Perez Del Nogal G, Modi R, Salinas I, Chakrala K. Incidental massive lower gastrointestinal hemorrhage caused by a rectal Dieulafoy's lesion. BMJ Case Rep 2021; 14:e244264. [PMID: 34497057 PMCID: PMC8438715 DOI: 10.1136/bcr-2021-244264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 11/04/2022] Open
Abstract
A Dieulafoy's lesion is a rare cause of massive gastrointestinal (GI) bleeding. It represents an abnormally dilated submucosal artery that erodes the overlying epithelium in the absence of a primary ulcer. These lesions are usually located in the stomach, nevertheless, they have been found in all areas of the GI tract, including the oesophagus, duodenum and colon. Bleeding episodes are often self-limited, although bleeding can be recurrent and profuse. The case describes a 50-year-old woman who developed haemorrhagic shock secondary to a rectal Dieulafoy's lesion and discusses the diagnostic and therapeutic approaches.
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Affiliation(s)
- Genesis Perez Del Nogal
- Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Permian Basin, Odessa, Texas, USA
| | - Rangesh Modi
- Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Permian Basin, Odessa, Texas, USA
| | - Ivania Salinas
- Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Permian Basin, Odessa, Texas, USA
| | - Kalyan Chakrala
- Gastroenterology, Medical Center Hospital, Odessa, Texas, USA
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16
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Wang Y, Bansal P, Li S, Iqbal Z, Cheryala M, Abougergi MS. Dieulafoy's lesion of the upper GI tract: a comprehensive nationwide database analysis. Gastrointest Endosc 2021; 94:24-34.e5. [PMID: 33359438 DOI: 10.1016/j.gie.2020.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/03/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS We sought to determine the incidence, risk factors, and treatment outcomes of Dieulafoy's lesion of the upper GI tract (UDL) hemorrhage among adult patients in the United States. METHODS UDL and non-Dieulafoy upper GI bleeding (UGIB) were identified from the Nationwide Inpatient Sample and Nationwide Readmission Database using International Classification of Diseases, Tenth Revision, Clinical Modification and Procedure Coding System codes. Multivariate logistic (binary) and linear (continuous) regressions were used to model dependent variables. RESULTS The incidence of UDL hemorrhage was 1.6 of 100,000 persons. Patients with UDL and UGIB who required endoscopic therapeutic intervention had similar in-hospital (adjusted odds ratio [aOR], .77; 95% confidence interval [CI], .42-1.43; P = .41) mortality rates. UDL was associated with more severe systemic illness, including higher rates of mechanical ventilation (aOR, 1.52; 95% CI, 1.07-2.15; P < .05), hypovolemic shock (aOR, 1.50; 95% CI, 1.08-2.08; P < .05), acute kidney injury (aOR, 1.25; 95% CI, 1.02-1.54; P < .05), and multiple endoscopies (aOR, 1.57; 95% CI, 1.28-1.93; P < .05) compared with other UGIB patients who required endoscopic therapeutic intervention. UDL was also associated with higher 30-day all-cause (aOR, 1.23; 95% CI, 1.12-1.35; P < .05) and recurrent bleeding-related (aOR, 1.73; 95% CI, 1.45-2.06; P < .05) readmissions. The rate of successful endoscopic treatment was 96.81%. CONCLUSIONS UDL hemorrhage is an uncommon but highly morbid condition. Current UDL treatment modalities are effective in reducing mortality. Further investigations are warranted to lower recurrent bleeding rates.
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Affiliation(s)
- Yichen Wang
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Pardeep Bansal
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA; Division of Gastroenterology, Regional Hospital and Moses Taylor Hospital, Scranton, Pennsylvania, USA
| | - Si Li
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Zaid Iqbal
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Mahesh Cheryala
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Marwan S Abougergi
- Catalyst Medical Consulting, Simpsonville, South Carolina, USA; Division of Gastroenterology, Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA
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17
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Ribeiro AM, da Silva S, Reis RA, Romero I, Costa S, da Silva JB. Dieulafoy's lesion in the cecum: A rare case report presentation. Int J Surg Case Rep 2021; 84:106157. [PMID: 34225059 PMCID: PMC8261652 DOI: 10.1016/j.ijscr.2021.106157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/24/2021] [Accepted: 06/26/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction and importance Dieulafoy's lesion is a rare entity, normally present in the stomach and more rarely in the colon, and it is responsible for 1% to 5% of acute gastrointestinal bleeding cases. Its true incidence may be underrated, since most cases are asymptomatic and difficult to diagnose despite endoscopic advances. We present a clinical case of acute gastrointestinal bleeding due to Dieulafoy's lesion in the cecum. Case presentation An 85-year-old woman presented with a clinical condition of haematochezia associated with anaemia and haemodynamic instability, needing blood transfusion. Colonoscopy demonstrated a Dieulafoy's lesion in the cecum with active bleeding, and haemostasis was performed successfully with localized adrenaline injection and haemostatic clip placement. Hospitalization occurred without further complications. Discussion The diagnosis of Dieulafoy's lesion is difficult because it is a rare condition and thus, usually not included in the differential diagnosis of gastrointestinal bleeding. Its endoscopic diagnostic and therapeutic approach is the standard method in the event of an acute gastrointestinal bleeding episode, with greater efficiency with the combined use of haemostatic techniques. Surgery is necessary in less than 5% of cases when bleeding is not effectively controlled by endoscopic or angiographic techniques. Conclusion It is essential to be aware of this lesion as a possible cause of gastrointestinal bleeding and differentiate it from other causes. Advances in endoscopy have increased the rate of diagnosis of these lesions and reduced their associated mortality. Dieulafoy's lesion is a rare entity and is mostly found in the stomach. This lesion is an uncommon cause of acute gastrointestinal bleeding. Its diagnosis is difficult due to its rarity. This case report presents a Dieulafoy's lesion in the colon, an even rarer location.
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Affiliation(s)
- Ana Matos Ribeiro
- Department of General Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal.
| | - Sílvia da Silva
- Department of General Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Rui Almeida Reis
- Department of General Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Inês Romero
- Department of General Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Susana Costa
- Department of General Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - João Barros da Silva
- Department of General Surgery, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
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19
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Malik A, Inayat F, Goraya MHN, Almas T, Ishtiaq R, Malik S, Tarar ZI. Jejunal Dieulafoy's Lesion: A Systematic Review of Evaluation, Diagnosis, and Management. J Investig Med High Impact Case Rep 2021; 9:2324709620987703. [PMID: 33472441 PMCID: PMC7829607 DOI: 10.1177/2324709620987703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/10/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022] Open
Abstract
Jejunal Dieulafoy's lesion is an exceedingly rare but important cause of gastrointestinal bleeding. It frequently presents as a diagnostic and therapeutic conundrum due to the rare occurrence, intermittent bleeding symptoms often requiring prompt clinical action, variability in the detection and treatment methods, and the risk of rebleeding. We performed a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases regarding jejunal Dieulafoy's lesio from inception till June 2020. A total of 136 cases were retrieved from 76 articles. The mean age was 55 ± 24 years, with 55% of cases reported in males. Patients commonly presented with melena (33%), obscure-overt gastrointestinal bleeding (29%), and hemodynamic compromise (20%). Hypertension (26%), prior gastrointestinal surgery (14%), and valvular heart disease (13%) were the major underlying disorders. Conventional endoscopy often failed but single- and double-balloon enteroscopy identified the lesion in 96% and 98% of patients, respectively. There was no consensus on the treatment. Endoscopic therapy was instituted in 64% of patients. Combination therapy (34%) with two or more endoscopic modalities, was the preferred approach. With regard to endoscopic monotherapy, hemoclipping (19%) and argon plasma coagulation (4%) were frequently employed procedures. Furthermore, direct surgical intervention in 32% and angiographic embolization was performed in 4% of patients. The rebleeding rate was 13.4%, with a mean follow-up duration of 17.6 ± 21.98 months. The overall mortality rate was 4.4%. Jejunal Dieulafoy's lesion is still difficult to diagnose and manage. Although the standard diagnostic and therapeutic modalities remain to be determined, device-assisted enteroscopy might yield promising outcomes.
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Affiliation(s)
- Adnan Malik
- Loyola University Medical Center,
Maywood, IL, USA
| | - Faisal Inayat
- Allama Iqbal Medical College, Lahore,
Punjab, Pakistan
| | | | - Talal Almas
- Royal College of Surgeons in Ireland,
Dublin, Ireland
| | | | - Sohira Malik
- Nishter Medical University, Multan,
Punjab, Pakistan
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20
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Massinha P, Cunha I, Tomé L. Dieulafoy Lesion: Predictive Factors of Early Relapse and Long-Term Follow-Up. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:237-243. [PMID: 32775545 DOI: 10.1159/000504720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/18/2019] [Indexed: 12/15/2022]
Abstract
Introduction The Dieulafoy lesion (DL) is a rare cause of gastrointestinal bleeding. Advances in the endoscopy field have allowed an increased rate of detection and therapeutic efficacy. However, doubts remain about the most effective hemostatic approach, the affecting variables of therapeutic failure, and early relapse, as well as in the long-term follow-up. Aims To assess the efficacy of endoscopic treatment of DL and to identify possible risk factors for early relapse and long-term results. Methods All patients with DL admitted to a tertiary hospital between 01/01/2007 and 12/31/2018 were evaluated. The form of presentation, associated pathologies, chronic medication, therapeutic approach, and eventual relapse were determined. A telephone interview was conducted for all patients to find out the long-term results. Results We identified 73 patients with DL, 45 (61.6%) males, with a mean age of 74 ± 15 years. Thirty-nine patients presented the DL in the stomach, 15 in the duodenum, 2 in the small bowel, 3 in the colon, and 11 in the rectum. The median number of endoscopic examinations required for diagnosis was 2. Median Rockall was 4 (range 2-7). After endoscopic treatment, in 95% of the cases, no active bleeding was evident. Only 2 patients required interventional radiology procedures and 1 needed surgery. Fourteen patients (19%) had a rebleeding, 12 during hospitalization and 2 after a median time of 51 months (range 1-117). There was no difference between the groups with and without early relapse in relation to age, gender, hemoglobin values at presentation, presence of shock, associated pathologies, and anticoagulation. Antiplatelet agents intake had a statistically significant relationship with early relapse (p = 0.003). Conclusion Endoscopic therapy is safe and effective in DL. Patients under antiplatelet therapy are more likely to have an early relapse. The long-term prognosis is excellent, even in patients only treated with endoscopic methods.
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Affiliation(s)
- Paulo Massinha
- Gastroenterology Department, Garcia de Orta Hospital, E.P.E., Almada, Portugal.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Inês Cunha
- Gastroenterology Department, Coimbra Hospital and Universitary Centre, E.P.E., Coimbra, Portugal
| | - Luís Tomé
- Gastroenterology Department, Coimbra Hospital and Universitary Centre, E.P.E., Coimbra, Portugal.,Faculty of Medicine of the University of Coimbra, Coimbra, Portugal
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21
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A case of the lower gastrointestinal bleeding due to Dieulafoy’s ulcer in the cecum. Clin J Gastroenterol 2020; 13:564-567. [PMID: 32125663 PMCID: PMC7395049 DOI: 10.1007/s12328-020-01109-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/18/2020] [Indexed: 02/07/2023]
Abstract
AbstractGastrointestinal Dieulafoy’s ulcer is a rare disease of unknown etiology. Dieulafoy’s ulcer often presents in the stomach and is thought to cause about 5% of all gastrointestinal bleeds in adults, but can be found in any part of the gastrointestinal tract. Dieulafoy’s ulcer corresponds to an arterial malformation in the submucosal space and can cause life-threatening hemorrhage. We report a case of the lower gastrointestinal bleeding from a cecal Dieulafoy’s ulcer that was successfully treated with endoscopic clips. An 82-year-old woman had been diagnosed with hypertension and cerebral infarction. She had been using aspirin to prevent recurrent infarction. She was admitted to our hospital with hematochezia. Urgent colonoscopy revealed a small, reddish vascular malformation in the cecum. The lesion was suggestive of Dieulafoy’s ulcer and was treated with endoscopic clips. The patient has since been discharged from our hospital without experiencing any further bleeding. Endoscopy is a useful method for diagnosing and treating Dieulafoy’s ulcer.
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22
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Miralles O, Ariza D, Ariza J, Fontecha B. [Bleeding from Dieulafoy's lesion: a case report on a nonagenarian man and a review of the literature]. Rev Esp Geriatr Gerontol 2020; 55:244-245. [PMID: 31879155 DOI: 10.1016/j.regg.2019.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 10/21/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Oriol Miralles
- Servicio de Geriatría y Cuidados Paliativos, Hospital Sociosanitario de L'Hospitalet de Llobregat - Consorci Sanitari Integral, L'Hospitalet de Llobregat, Barcelona, España.
| | - Diana Ariza
- Servicio de Geriatría y Cuidados Paliativos, Hospital Sociosanitario de L'Hospitalet de Llobregat - Consorci Sanitari Integral, L'Hospitalet de Llobregat, Barcelona, España
| | - Javier Ariza
- Servicio de Digestivo, Hospital Sant Joan Despí Moisès Broggi - Consorci Sanitari Integral, Sant Joan Despí, Barcelona, España
| | - Benito Fontecha
- Servicio de Geriatría y Cuidados Paliativos, Hospital Sociosanitario de L'Hospitalet de Llobregat - Consorci Sanitari Integral, L'Hospitalet de Llobregat, Barcelona, España
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23
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Mujtaba S, Chawla S, Massaad JF. Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives. J Clin Med 2020; 9:jcm9020402. [PMID: 32024301 PMCID: PMC7074258 DOI: 10.3390/jcm9020402] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/30/2023] Open
Abstract
Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.
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24
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Abstract
Upper gastrointestinal bleeding (UGIB), defined as intraluminal hemorrhage proximal to the ligament of Treitz, can range from mild and asymptomatic to massive life-threatening hemorrhage. For the purposes of this article, the authors define an acute UGIB to be one that results in new acute symptoms and is, therefore, potentially life-threatening. UGIB requires a systematic approach to evaluation and treatment, similar to the management of a trauma patient. Surgeon involvement in UGIBs remains integral despite the rare need for operative management. Endoscopy is the primary tool for diagnosis and treatment.
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Affiliation(s)
- David W Nelms
- General Surgery Residency Program, UnityPoint Health, 1415 Woodland Avenue, Suite 130, Des Moines, IA 50309, USA
| | - Carlos A Pelaez
- General Surgery Residency Program, UnityPoint Health, 1415 Woodland Avenue, Suite 130, Des Moines, IA 50309, USA; General Surgery, Trauma and Critical Care, The Iowa Clinic, 1212 Pleasant Street, Suite 211, Des Moines, IA 50309, USA; Trauma Services, UnityPoint Health, Iowa Methodist Medical Center, 1200 Pleasant Street, Des Moines, IA 50309, USA.
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25
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Inayat F, Amjad W, Hussain Q, Hurairah A. Dieulafoy's lesion of the duodenum: a comparative review of 37 cases. BMJ Case Rep 2018; 2018:bcr-2017-223246. [PMID: 29472423 PMCID: PMC5847980 DOI: 10.1136/bcr-2017-223246] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2018] [Indexed: 12/17/2022] Open
Abstract
Dieulafoy's lesion is an abnormally large, tortuous, submucosal vessel that erodes the overlying epithelium without primary ulceration or erosion. The lesion predominantly occurs in the proximal stomach but it is also reported in extragastric sites. The pathogenesis and precipitating factors are poorly understood. Patients frequently present with gastrointestinal haemorrhage that can range from being self-limited to massive life threatening. Although there are no standard guidelines, endoscopy has significantly impacted the diagnosis and management. This review outlines our current understanding of the epidemiology of and risk factors for Dieulafoy's lesion of the duodenum, the pathophysiology of this disorder, and currently available approaches to diagnosis and management.
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Affiliation(s)
| | - Waseem Amjad
- Northwell-Long Island Jewish Forest Hills Hospital, Forest Hills, NY, USA
| | | | - Abu Hurairah
- SUNY Downstate Medical Center, Brooklyn, NY, USA
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26
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Nadhem ON, Salh OA, Bazzaz OH. Lower gastrointestinal bleeding due to rectal Dieulafoy's lesion. SAGE Open Med Case Rep 2017; 5:2050313X17744982. [PMID: 29238577 PMCID: PMC5721951 DOI: 10.1177/2050313x17744982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 11/06/2017] [Indexed: 11/15/2022] Open
Abstract
Dieulafoy’s lesion is a relatively rare but serious cause of gastrointestinal bleeding. It usually involves the upper gastrointestinal tract. However, it has recently been reported in different regions of the gastrointestinal tract, including the rectum. Here, we report the case of a female patient who presented with fresh bleeding per rectum for 1 day with low hemoglobin level. Colonoscopy revealed an actively bleeding rectal Dieulafoy’s lesion which was successfully treated with a clip. To our knowledge, there have been few reported cases of lower gastrointestinal bleeding caused by Dieulafoy’s lesion in the rectum.
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Affiliation(s)
- Omar N Nadhem
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - Omar A Salh
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - Omar H Bazzaz
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, USA
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27
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Abstract
Dieulafoy's lesions (DLs) are rare and cause gastrointestinal bleeding resulting from erosion of dilated submucosal vessels. The most common location for DL is the stomach, followed by duodenum. There is little information about duodenal and jejunal DLs. Challenges for diagnosis and treatment of Dieulafoy's lesions include the rare nature of the disease, asymptomatic patients, bleeding symptoms often requiring rapid diagnosis and treatment in symptomatic patients, variability in the diagnosis and treatment methods resulting from different lesion locations, and the risk of re-bleeding. For these reasons, there is no universal consensus about the diagnosis and treatment approach. There are few published case reports and case series recently published. Most duodenal DLs are not evaluated seperately in the studies, which makes it difficult to determine the optimal model. In this study, we summarize the general aspects and recent approaches used to treat duodenal DL.
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Affiliation(s)
- Tonguç Utku Yılmaz
- Acibadem University Atakent Hospital, Organ Transplantation Unit, Istanbul, Turkey
| | - Ramazan Kozan
- Eren Hospital, General Surgery Unit, Istanbul, Turkey
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28
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Inayat F, Ullah W, Hussain Q, Abdullah HMA. Dieulafoy's lesion of the colon and rectum: a case series and literature review. BMJ Case Rep 2017; 2017:bcr-2017-220431. [PMID: 29070617 DOI: 10.1136/bcr-2017-220431] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Dieulafoy's lesion is a dilated, aberrant, submucosal vessel that erodes the overlying epithelium without obvious ulceration. It is most commonly located in the lesser curvature of the stomach but rare occurrences in extragastric sites have also been reported. Herein, we describe a case series of three patients who presented with lower gastrointestinal bleeding. Colonoscopy revealed a caliber-persistent tortuous submucosal artery protruding into the lumen of the colon or rectum. The patients were diagnosed with Dieulafoy's lesion and primary haemostasis was achieved with the endoscopic haemoclip application. The purpose of this review is to summarise the available data on the pathophysiology, epidemiology, clinical presentation, diagnosis and management of patients with Dieulafoy's lesion of the colon and rectum.
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29
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Wang M, Bu X, Zhang J, Zhu S, Zheng Y, Tantai X, Ma S. Dieulafoy's lesion of the rectum: a case report and review of the literature. Endosc Int Open 2017; 5:E939-E942. [PMID: 28924603 PMCID: PMC5597931 DOI: 10.1055/s-0043-114661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 05/02/2017] [Indexed: 02/06/2023] Open
Abstract
One patient with Dieulafoy's lesion (DL) of the rectum who had a history of anal receptive intercourse is described and the relevant literature reviewed. DL is rare in clinical practice and is extremely rare in the rectum. It often affects patients with no history of cirrhosis or gastrointestinal disease and occurs with abrupt or recurrent gastrointestinal bleeding. Visible vessels can usually be found by endoscopy and coinstantaneous treatments are essential while surgical interventions can occur when necessary. The diagnosis of DL is mainly based on clinical manifestations and endoscopic features, and endoscopic treatment is the first option for hemostasis.
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Affiliation(s)
| | | | | | | | | | | | - Shiyang Ma
- Division of Gastroenterology, The Second Affiliated Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi 710004, PR China,Corresponding author Shiyang Ma, MD Division of GastroenterologyThe Second Affiliated HospitalXi’an Jiaotong UniversityNo. 157Xi Wu RoadXi’anShaanxi 710004PR China+86-29-87679290
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30
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Cotter TG, Buckley NS, Loftus CG. Approach to the Patient With Hematochezia. Mayo Clin Proc 2017; 92:797-804. [PMID: 28473039 DOI: 10.1016/j.mayocp.2016.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/03/2016] [Accepted: 12/09/2016] [Indexed: 02/07/2023]
Abstract
The evaluation of the patient with hematochezia can be complex because of the broad differential diagnosis and the number of management strategies available. In this article, a simplified approach to the history and physical examination is presented, with management illustrated in a case-oriented manner.
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Affiliation(s)
| | - Niamh S Buckley
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Conor G Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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31
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Inayat F, Ullah W, Hussain Q, Hurairah A. Dieulafoy's lesion of the oesophagus: a case series and literature review. BMJ Case Rep 2017; 2017:bcr-2016-218100. [PMID: 28062437 DOI: 10.1136/bcr-2016-218100] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Dieulafoy's lesion is a vascular abnormality consisting of a tortuous, dilated aberrant submucosal vessel that erodes the overlying mucosal layer without ulceration. The oesophagus is a very rare location for the lesion. Herein, we report a case series of 3 patients who presented with upper gastrointestinal bleeding. Endoscopy was performed, which showed a large calibre-persistent tortuous submucosal artery protruding into the oesophageal lumen. All the patients were successfully managed with endoscopic intervention using epinephrine injection around the lesion followed by hemoclip application. The present paper highlights the remarkably rare occurrence of oesophageal Dieulafoy's lesion and reviews the pathophysiology, epidemiology and management with a focus on diagnostic challenge encountered in such patients.
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Affiliation(s)
- Faisal Inayat
- New York-Presbyterian Hospital, Weill Cornell Medical College, New York City, New York, USA
| | | | | | - Abu Hurairah
- SUNY Downstate Medical Center, New York, New York, USA
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32
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Qiao WG, Ren YT, Liu SD, Zhi FC. Gastroscopy: Advancing further into the horizontal part of the duodenum. J Dig Dis 2017; 18:56-58. [PMID: 27990757 DOI: 10.1111/1751-2980.12434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 11/17/2016] [Accepted: 12/08/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Wei Guang Qiao
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Yu Tang Ren
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Beijing, China
| | - Si De Liu
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Fa Chao Zhi
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Institute of Gastroenterology of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
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Chen X, Cao H, Wang S, Wang D, Xu M, Piao M, Wang B. Endoscopic submucosal dissection for silent gastric Dieulafoy lesions mimicking gastrointestinal stromal tumors: Report of 7 cases-a case report series. Medicine (Baltimore) 2016; 95:e4829. [PMID: 27603399 PMCID: PMC5023922 DOI: 10.1097/md.0000000000004829] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Dieulafoy lesion is a rare but serious cause of gastrointestinal hemorrhage. However, some cases can be occasionally found without bleeding during the endoscopic screening, and the management remains unclear. The aim of this article was to report the efficacy and safety of endoscopic submucosal dissection (ESD) for silent gastric Dieulafoy lesions, which presented as protrusion lesions mimicking gastrointestinal stromal tumors (GISTs). METHODS Data from the patients with gastric protrusion lesions who underwent ESD from September 2008 to April 2016 in General Hospital, Tianjin Medical University, China were recorded. Seven cases with pathological diagnosis of Dieulafoy lesion without bleeding were enrolled for further analysis. RESULTS A total of 7 patients (2 males and 5 females) with mean age of 57.7 ± 4.15 years were pathologically diagnosed as Dieulafoy lesion. Four of the lesions were located in gastric antrum, 2 in the fundus, and 1 in the body of stomach, respectively. The mean sizes of the Dieulafoy lesions under white light endoscopy and endoscopic ultrasonography (EUS) were 1.06 ± 0.28 and 0.84 ± 0.29 cm. The origins of these lesions were submucosa (6/7, 85.7%) and muscularis propria (1/7, 14.3%). Three of them appeared with mixed echo under EUS, 3 with hypoechogenicity, and 1 with hyperechogenicity. En bloc complete resection was achieved in all the lesions by ESD with average time of 76.00 ± 16.86 minutes, and no intraoperative bleeding happened. In addition, all patients were followed up for 1 to 53 months, and no recurrence or long-term complications was observed. CONCLUSION Therefore, ESD can be an effective and safe treatment for silent gastric Dieulafoy lesions with clinical presentations of submucosal protrusion lesions mimicking GISTs.
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Affiliation(s)
- Xue Chen
- Department of Gastroenterology and Hepatology
| | - Hailong Cao
- Department of Gastroenterology and Hepatology
- Correspondence: Hailong Cao, Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Heping District 154 Anshan Road, Tianjin 300052, China (e-mail: )
| | - Sinan Wang
- Department of Gastroenterology and Hepatology
| | - Dan Wang
- Department of Pathology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Mengque Xu
- Department of Gastroenterology and Hepatology
| | - Meiyu Piao
- Department of Gastroenterology and Hepatology
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Sathyamurthy A, Winn JN, Ibdah JA, Tahan V. Culprit for recurrent acute gastrointestinal massive bleeding: “Small bowel Dieulafoy’s lesions” - a case report and literature review. World J Gastrointest Pathophysiol 2016; 7:296-299. [PMID: 27574568 PMCID: PMC4981770 DOI: 10.4291/wjgp.v7.i3.296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/02/2016] [Accepted: 07/18/2016] [Indexed: 02/07/2023] Open
Abstract
A Dieulafoy's lesion is a dilated, aberrant, submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. It can be located anywhere in the gastrointestinal tract. We describe a case of massive gastrointestinal bleeding from Dieulafoy’s lesions in the duodenum. Etiology and precipitating events of a Dieulafoy’s lesion are not well known. Bleeding can range from being self-limited to massive life- threatening. Endoscopic hemostasis can be achieved with a combination of therapeutic modalities. The endoscopic management includes sclerosant injection, heater probe, laser therapy, electrocautery, cyanoacrylate glue, banding, and clipping. Endoscopic tattooing can be helpful to locate the lesion for further endoscopic re-treatment or intraoperative wedge resection. Therapeutic options for re-bleeding lesions comprise of repeated endoscopic hemostasis, angiographic embolization or surgical wedge resection of the lesions. We present a 63-year-old Caucasian male with active bleeding from the two small bowel Dieulafoy’s lesions, which was successfully controlled with epinephrine injection and clip applications.
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Dieulafoy lesion of the gallbladder presenting with bleeding and a pseudo-mirizzi syndrome: A case report and review of the literature. Int J Surg Case Rep 2016. [PMID: 26878358 DOI: 10.1016/j.ijscr.2016.01.034.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Gastrointestinal bleeding can have significant morbidity and mortality. Pathological processes that cause it are diverse, and timely investigation and management are vital. Dieulafoy lesions are a rare cause of gastrointestinal bleeding and here we describe a case of a gallbladder dieulafoy lesion causing gastrointestinal bleeding. PRESENTATION OF CASE Recently discharged from hospital following an open anterior resection and loop ileostomy for diverticular disease, an 84-year-old female re-presented with lower abdominal pain associated with jaundice and lymphocytosis. Imaging demonstrated two possible rectal stump collections (treated with antibiotics), and heterogeneous material in the gallbladder. The patient deteriorated, developing melena, coffee ground vomitus and right upper quadrant pain. Investigation sourced the bleeding to the gallbladder that resolved following cholecystectomy, and histopathology was consistent with a dieulafoy lesion. The patient made a full recovery. DISCUSSION Dieulafoy lesions have rarely been reported in the gallbladder, and as such can be an occult source of massive gastrointestinal bleeding. It should be considered where gastrointestinal bleeding accompanies jaundice and abdominal pain. CONCLUSION This case highlights that dieulafoy lesions can occur in the gallbladder. Massive gastrointestinal bleeding can occur within the gallbladder, and a gallbladder dieulafoy lesion should be considered as a potential cause of such, especially when a source has not been identified on endoscopy. It also demonstrates the effectiveness of cholecystectomy as a definitive management strategy.
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Stanes A, Mackay S. Dieulafoy lesion of the gallbladder presenting with bleeding and a pseudo-mirizzi syndrome: A case report and review of the literature. Int J Surg Case Rep 2016; 21:12-5. [PMID: 26878358 PMCID: PMC4802134 DOI: 10.1016/j.ijscr.2016.01.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 01/27/2016] [Accepted: 01/28/2016] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Gastrointestinal bleeding can have significant morbidity and mortality. Pathological processes that cause it are diverse, and timely investigation and management are vital. Dieulafoy lesions are a rare cause of gastrointestinal bleeding and here we describe a case of a gallbladder dieulafoy lesion causing gastrointestinal bleeding. PRESENTATION OF CASE Recently discharged from hospital following an open anterior resection and loop ileostomy for diverticular disease, an 84-year-old female re-presented with lower abdominal pain associated with jaundice and lymphocytosis. Imaging demonstrated two possible rectal stump collections (treated with antibiotics), and heterogeneous material in the gallbladder. The patient deteriorated, developing melena, coffee ground vomitus and right upper quadrant pain. Investigation sourced the bleeding to the gallbladder that resolved following cholecystectomy, and histopathology was consistent with a dieulafoy lesion. The patient made a full recovery. DISCUSSION Dieulafoy lesions have rarely been reported in the gallbladder, and as such can be an occult source of massive gastrointestinal bleeding. It should be considered where gastrointestinal bleeding accompanies jaundice and abdominal pain. CONCLUSION This case highlights that dieulafoy lesions can occur in the gallbladder. Massive gastrointestinal bleeding can occur within the gallbladder, and a gallbladder dieulafoy lesion should be considered as a potential cause of such, especially when a source has not been identified on endoscopy. It also demonstrates the effectiveness of cholecystectomy as a definitive management strategy.
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Affiliation(s)
- Aaron Stanes
- Eastern Health Surgical Research Group, Monash University, Eastern Health Clinical School, 5 Arnold St, Box Hill, Melbourne, Victoria 3128, Australia.
| | - Sean Mackay
- Eastern Health Surgical Research Group, Monash University, Eastern Health Clinical School, 5 Arnold St, Box Hill, Melbourne, Victoria 3128, Australia.
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Li SL, Jing FY, Ma LL, Guo LL, Na F, An SL, Ye Y, Yang JM, Bao M, Kang D, Sun XL, Deng YJ. Myofibrotic malformation vessels: unique angiodysplasia toward the progression of hemorrhoidal disease. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:4649-56. [PMID: 26316703 PMCID: PMC4541538 DOI: 10.2147/dddt.s90209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The etiology and pathogenesis of hemorrhoids is unclear, although hemorrhoids are a worldwide disease in men and women, with peak prevalence at 45–65 years of age. Hemorrhoidal cushions as the anal venous plexi are normal anatomical structures from infancy. This study attempts to reveal the angiodysplasia and other pathological changes in association with different degrees of symptomatic hemorrhoids. Materials and methods A total of 281 patients with internal hemorrhoids from degree I to IV underwent hemorrhoidectomy. The vascular changes were analyzed by microscopic assessment and software analysis, with Masson’s trichrome, CD34, and smooth muscle actin. Results The hemorrhoidal tissues exhibited abnormal vessels in the mucosae and submucosae that we termed them as myofibrotic malformation vessels (MMVs). MMVs are not ascribed to arteries or veins because they exhibit enlarged and tortuous lumens with smooth muscle dysplasia and fibrotic deposition in the walls without overlying mucosal ulceration. The muscularis mucosae also showed smooth muscle dysplasia and fibrosis, even if it were interrupted by the intruding MMVs. The statistical data indicated that the severity of all the changes correlate positively with the progression of hemorrhoids (P<0.001). Hemorrhoidal patients are prone for reoccurrence even with prolapsing hemorrhoid when compared with the conventional hemorrhoidectomy. Multiple logistic regression analysis showed that MMVs in mucosal propria, mean thickness of mucosal muscularis layer, and fibrotic changes in MMV were independent risk factors for MMVs in hemorrhoidal disease. Conclusion MMVs and muscularis mucosae dysplasia reciprocally contribute to hemorrhoidal exacerbation. The novel findings of this study propose that the characteristic features of MMVs and muscularis mucosae dysplasia of the anorectal tube ultimately cause symptomatic hemorrhoids, which could affect the clinical management of hemorrhoidal disease through the use of surgery to target the malformed vessels.
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Affiliation(s)
- Sheng-Long Li
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Fang-Yan Jing
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
| | - Li-Li Ma
- Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
| | - Li-Li Guo
- Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
| | - Feng Na
- Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
| | - Sheng-Li An
- Department of Biostatistics, Southern Medical University, Zengcheng, Guangzhou, People's Republic of China
| | - Yan Ye
- Department of General Surgery, Xintang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Jun-Ming Yang
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Ming Bao
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Dong Kang
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Xiao-Lan Sun
- Department of Anorectal Surgery, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China
| | - Yong-Jian Deng
- Department of Pathology, Nanfang Hospital, Zengcheng, Guangzhou, People's Republic of China ; Department of Pathology, School of Basic Medical Sciences, Zengcheng, Guangzhou, People's Republic of China
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Abstract
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.
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Khan R, Mahmad A, Gobrial M, Onwochei F, Shah K. The Diagnostic Dilemma of Dieulafoy's Lesion. Gastroenterology Res 2015; 8:201-206. [PMID: 27785297 PMCID: PMC5040527 DOI: 10.14740/gr671w] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 12/17/2022] Open
Abstract
Dieulafoy’s lesion (DL) is a relatively rare condition which carries a significantly high risk for mortality. A tortuous large arteriole in the wall of the stomach can result in significant gastrointestinal (GI) hemorrhage which can result in detrimental complications. Although it only accounts for about 1% of all GI bleeding, it has been considered to be one of the most underrecognized conditions. This train of thought may unfortunately be related to the difficulty in its diagnosis. After conducting a Medline search of the medical literature, with a focus on current PubMed articles, a thorough examination of updated diagnostic and treatment approaches was compared. Diagnostic techniques in the analysis and treatment of DLs continue to be limited to this day. Endoscopy remains as the main diagnostic and therapeutic tool; however, it continues to have its limitations. Other alternatives include but are not limited to angiography and surgical interventions which at times can be more successful. Diagnostic improvements and research for the detection of DL continue to advance; however, they remain limited in their capabilities. Further analysis and workup needs to be conducted in order to reduce hospital stay and improve survival.
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Affiliation(s)
- Rafay Khan
- Internal Medicine Department, Raritan Bay Medical Center, 530 New Brunswick Avenue, Perth Amboy, NJ 08861, USA
| | - Abdul Mahmad
- Internal Medicine Department, Raritan Bay Medical Center, 530 New Brunswick Avenue, Perth Amboy, NJ 08861, USA
| | - Mark Gobrial
- Internal Medicine Department, Maimonides Medical Center, 4802 10th Ave, Brooklyn, NY 11219, USA
| | - Francis Onwochei
- Internal Medicine Department, Jersey City Medical Center, 355 Grand St, Jersey City, NJ 07302, USA
| | - Kunal Shah
- St. George's University School of Medicine, University Centre, Grenada, West Indies
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Shin HJ, Ju JS, Kim KD, Kim SW, Kang SH, Kang SH, Moon HS, Sung JK, Jeong HY. Risk Factors for Dieulafoy Lesions in the Upper Gastrointestinal Tract. Clin Endosc 2015; 48:228-33. [PMID: 26064823 PMCID: PMC4461667 DOI: 10.5946/ce.2015.48.3.228] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 10/13/2014] [Accepted: 10/19/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS The purpose of this study is to verify the risk factors associated with Dieulafoy lesion formation in the upper gastrointestinal tract. METHODS A case-control study was performed by reviewing the electronic medical records of 42 patients who were admitted to a tertiary medical center in the Daejeon region for Dieulafoy lesions from September 2008 to October 2013, and the records of 132 patients who were admitted during the same period and who underwent endoscopic examination for reasons other than bleeding. We analyzed clinical and endoscopic findings retrospectively, and searched for risk factors associated with Dieulafoy lesion formation. RESULTS All 42 patients diagnosed with Dieulafoy lesion had accompanying bleeding, and the location of the bleeding was proximal in 25 patients (59.5%), the middle portion in seven patients (16.7%), and distal in 10 patients (23.8%). Antiplatelet agents (p=0.022) and alcohol (p=0.001) use showed statistically significant differences between the two groups. The odds ratios (95% confidence intervals) of the two factors were 2.802 (1.263 to 6.217) and 3.938 (1.629 to 9.521), respectively. CONCLUSIONS This study showed that antiplatelet agents and alcohol consumption were risk factors associated with Dieulafoy lesion formation in the upper gastrointestinal tract.
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Affiliation(s)
- Hae Jin Shin
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jong Seok Ju
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Ki Dae Kim
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Seok Won Kim
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sung Hoon Kang
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun Hyung Kang
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hee Seok Moon
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Kyu Sung
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyun Yong Jeong
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
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Nojkov B, Cappell MS. Gastrointestinal bleeding from Dieulafoy's lesion: Clinical presentation, endoscopic findings, and endoscopic therapy. World J Gastrointest Endosc 2015; 7:295-307. [PMID: 25901208 PMCID: PMC4400618 DOI: 10.4253/wjge.v7.i4.295] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/20/2014] [Accepted: 01/09/2015] [Indexed: 02/05/2023] Open
Abstract
Although relatively uncommon, Dieulafoy's lesion is an important cause of acute gastrointestinal bleeding due to the frequent difficulty in its diagnosis; its tendency to cause severe, life-threatening, recurrent gastrointestinal bleeding; and its amenability to life-saving endoscopic therapy. Unlike normal vessels of the gastrointestinal tract which become progressively smaller in caliber peripherally, Dieulafoy's lesions maintain a large caliber despite their peripheral, submucosal, location within gastrointestinal wall. Dieulafoy's lesions typically present with severe, active, gastrointestinal bleeding, without prior symptoms; often cause hemodynamic instability and often require transfusion of multiple units of packed erythrocytes. About 75% of lesions are located in the stomach, with a marked proclivity of lesions within 6 cm of the gastroesophageal junction along the gastric lesser curve, but lesions can also occur in the duodenum and esophagus. Lesions in the jejunoileum or colorectum have been increasingly reported. Endoscopy is the first diagnostic test, but has only a 70% diagnostic yield because the lesions are frequently small and inconspicuous. Lesions typically appear at endoscopy as pigmented protuberances from exposed vessel stumps, with minimal surrounding erosion and no ulceration (visible vessel sans ulcer). Endoscopic therapy, including clips, sclerotherapy, argon plasma coagulation, thermocoagulation, or electrocoagulation, is the recommended initial therapy, with primary hemostasis achieved in nearly 90% of cases. Dual endoscopic therapy of epinephrine injection followed by ablative or mechanical therapy appears to be effective. Although banding is reportedly highly successful, it entails a small risk of gastrointestinal perforation from banding deep mural tissue. Therapeutic alternatives after failed endoscopic therapy include repeat endoscopic therapy, angiography, or surgical wedge resection. The mortality has declined from about 30% during the 1970's to 9%-13% currently with the advent of aggressive endoscopic therapy.
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Jeon HK, Kim GH. Endoscopic Management of Dieulafoy's Lesion. Clin Endosc 2015; 48:112-20. [PMID: 25844338 PMCID: PMC4381137 DOI: 10.5946/ce.2015.48.2.112] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 11/02/2014] [Accepted: 11/03/2014] [Indexed: 12/11/2022] Open
Abstract
A Dieulafoy's lesion is a vascular abnormality consisting of a large caliber-persistent tortuous submucosal artery. A small mucosal defect with the eruption of this protruding vessel can cause bleeding. In fact, a Dieulafoy's lesion is a relatively rare but potentially life-threatening condition. It accounts for 1% to 2% of cases of acute gastrointestinal bleeding. Although there is no consensus on the treatment of Dieulafoy's lesions; treatment options depend on the mode of presentation, site of the lesion, and available expertise. Endoscopic therapy is usually successful in achieving primary hemostasis, with hemostasis success rates reaching 75% to 100%. Although various therapeutic endoscopic methods are used to control bleeding in Dieulafoy's lesions, the best method for endoscopic intervention is not clear. Combination endoscopic therapy is known to be superior to monotherapy because of a lower rate of recurrent bleeding. In addition, mechanical therapies including hemostatic clipping and endoscopic band ligation are more effective and successful in controlling bleeding than other endoscopic methods. Advances in endoscopic techniques have reduced mortality in patients with Dieulafoy's lesion-from 80% to 8%-and consequently, the need for surgical intervention has been reduced. Currently, surgical intervention is used for cases that fail therapeutic endoscopic or angiographic interventions.
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Affiliation(s)
- Hye Kyung Jeon
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Tjwa ETTL, Holster IL, Kuipers EJ. Endoscopic management of nonvariceal, nonulcer upper gastrointestinal bleeding. Gastroenterol Clin North Am 2014; 43:707-19. [PMID: 25440920 DOI: 10.1016/j.gtc.2014.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Upper gastrointestinal bleeding (UGIB) is the most common emergency condition in gastroenterology. Although peptic ulcer and esophagogastric varices are the predominant causes, other conditions account for up to 50% of UGIBs. These conditions, among others, include angiodysplasia, Dieulafoy and Mallory-Weiss lesions, gastric antral vascular ectasia, and Cameron lesions. Upper GI cancer as well as lesions of the biliary tract and pancreas may also result in severe UGIB. This article provides an overview of the endoscopic management of these lesions, including the role of novel therapeutic modalities such as hemostatic powder and over-the-scope-clips.
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Affiliation(s)
- Eric T T L Tjwa
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - I Lisanne Holster
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO box 2040, 3000 CA, Rotterdam, The Netherlands
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44
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Colonic Dieulafoy's Lesion: A Rare Cause of Lower Gastrointestinal Hemorrhage and Review of Endoscopic Management. Case Rep Gastrointest Med 2014; 2014:436293. [PMID: 25386369 PMCID: PMC4217370 DOI: 10.1155/2014/436293] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 10/05/2014] [Indexed: 11/30/2022] Open
Abstract
Dieulafoy's lesions are a rare cause of gastrointestinal hemorrhage. Extragastric Dieulafoy's lesions are even more uncommon. We report the case of a 75-year-old woman who presented with gastrointestinal bleeding from a transverse colonic Dieulafoy's lesion. She presented with two episodes of melena followed by one episode of fresh blood per rectum. In addition, there was associated presyncope and anemia (hemoglobin 69 g/L) in the setting of supratherapeutic warfarin anticoagulation (INR 6.2) for nonvalvular atrial fibrillation. Esophagogastroduodenoscopy was negative for an upper GI source of bleeding but on colonoscopy an actively oozing Dieulafoy's lesion was identified in the transverse colon. Bipolar cautery and hemostatic endoclips were applied to achieve hemostasis. Clinicians should consider this rare entity as a potential cause of potentially life-threatening lower gastrointestinal bleeding and we review the endoscopic modalities effective for managing colonic Dieulafoy's lesions.
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Sánchez-Capilla AD, De La Torre-Rubio P, Redondo-Cerezo E. New insights to occult gastrointestinal bleeding: From pathophysiology to therapeutics. World J Gastrointest Pathophysiol 2014; 5:271-283. [PMID: 25133028 PMCID: PMC4133525 DOI: 10.4291/wjgp.v5.i3.271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 06/01/2014] [Accepted: 06/18/2014] [Indexed: 02/06/2023] Open
Abstract
Obscure gastrointestinal bleeding is still a clinical challenge for gastroenterologists. The recent development of novel technologies for the diagnosis and treatment of different bleeding causes has allowed a better management of patients, but it also determines the need of a deeper comprehension of pathophysiology and the analysis of local expertise in order to develop a rational management algorithm. Obscure gastrointestinal bleeding can be divided in occult, when a positive occult blood fecal test is the main manifestation, and overt, when external sings of bleeding are visible. In this paper we are going to focus on overt gastrointestinal bleeding, describing the physiopathology of the most usual causes, analyzing the diagnostic procedures available, from the most classical to the novel ones, and establishing a standard algorithm which can be adapted depending on the local expertise or availability. Finally, we will review the main therapeutic options for this complex and not so uncommon clinical problem.
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Elrazek AEMAA, Yoko N, Hiroki M, Afify M, Asar M, Ismael B, Salah M. Endoscopic management of Dieulafoy’s lesion using Isoamyl-2-cyanoacrylate. World J Gastrointest Endosc 2013; 5:417-419. [PMID: 23951399 PMCID: PMC3742709 DOI: 10.4253/wjge.v5.i8.417] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 07/01/2013] [Indexed: 02/05/2023] Open
Abstract
Dieulafoy’s lesion (DL) is a rare but important cause of obscure gastrointestinal bleeding that may be overlooked during diagnostic endoscopy. Mortality rates are similar to those of other causes for gastrointestinal bleeding. Diagnosis by upper endoscopy is the modality of choice during acute bleeding. In the absence of active bleeding, the lesion resembles a raised nipple or visible vessel. There are no guidelines regarding effective selective therapy for DL, when diagnosed, endoscopist experience is the major determinant of the treatment strategy. Following our strategy, an expert endoscopist with a skilled assistant should have a high rate of successful DL diagnosis when an obscured gastrointestinal lesion is suspected. Cyanoacryltes compounds have been used successfully in management of Gastric varices and DLs. To our knowledge, there have been no previous reports regarding use of isoamyl-2-cyanoacrylate (AMCRYLATE®; Concord Drugs Ltd., Hyderabad, India) as an effective therapy for gastric DL without serious complications. In our case study, Isoamyl-2-cyanoacrylate (AMCRYLATE®) was effective and safe for treating DL. Surgical wedge resection of the lesion should be considered as a therapeutic option if endoscopic therapy fails.
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Jamanca-Poma Y, Velasco-Guardado A, Piñero-Pérez C, Calderón-Begazo R, Umaña-Mejía J, Geijo-Martínez F, Rodríguez-Pérez A. Prognostic factors for recurrence of gastrointestinal bleeding due to Dieulafoy's lesion. World J Gastroenterol 2012; 18:5734-8. [PMID: 23155314 PMCID: PMC3484342 DOI: 10.3748/wjg.v18.i40.5734] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 07/26/2012] [Accepted: 07/28/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the effectiveness of the endoscopic therapy and to identify prognostic factors for recurrent bleeding.
METHODS: Retrospective study of patients with gastrointestinal bleeding secondary to Dieulafoy’s lesion (DL) from 2005 to 2011. We analyzed the demographic characteristics of the patients, risk factors for gastrointestinal bleeding, endoscopic findings, characteristics of the endoscopic treatment, and the recurrence of bleeding. We included cases in which endoscopy described a lesion compatible with Dieulafoy. We excluded patients who had potentially bleeding lesions such as angiodysplasia in other areas or had undergone other gastrointestinal endoscopic procedures.
RESULTS: Twenty-nine patients with DL were identified. Most of them were men with an average age of 71.5 years. Fifty-five percent of the patients received antiaggregatory or anticoagulant therapy. The most common location for DL was the stomach (51.7%). The main type of bleeding was oozing in 65.5% of cases. In 27.6% of cases, there was arterial (spurting) bleeding, and 6.9% of the patients presented with an adherent clot. A single endoscopic treatment was applied to nine patients (31%); eight of them with adrenaline and one with argon, while 69% of the patients received combined treatment. Six patients (20.7%) presented with recurrent bleeding at a median of 4 d after endoscopy (interquartile range = 97.75). Within these six patients, the new endoscopic treatment obtained a therapeutic success of 100%. The presence of arterial bleeding at endoscopy was associated with a higher recurrence rate for bleeding (50% vs 33.3% for other type of bleeding) [P = 0.024, odds ratio (OR) = 8.5, 95% CI = 1.13-63.87]. The use of combined endoscopic treatment prevented the recurrence of bleeding (10% vs 44.4% of single treatment) (P = 0.034, OR = 0.14, 95% CI = 0.19-0.99).
CONCLUSION: Endoscopic treatment of DL is safe and effective. Adrenaline monotherapy and arterial (spurting) bleeding are associated with a high rate of bleeding recurrence.
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Sevilla Chica FI, Bernet Vegué L, Martínez Benaclocha M, Torró Richart J. [Dieulafoy's lesion of the gallbladder as a cause of hemobilia with hemoperitoneum]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:690-3. [PMID: 22055829 DOI: 10.1016/j.gastrohep.2011.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 07/08/2011] [Accepted: 07/14/2011] [Indexed: 12/20/2022]
Abstract
Dieulafoy's lesion is an uncommon vascular anomaly causing massive gastrointestinal hemorrhage, characterized by bleeding from an arteriole that protrudes through a tiny mucosal defect. Although Dieulafoy's lesion was initially described in the stomach and upper gastrointestinal tract, cases have also been reported in the colon, rectum and anal canal. We report the first case of Dieulafoy's lesion in the gallbladder, which presented as massive peritoneal bleeding. We describe the clinical and pathological characteristics of this unusual entity, as well as the approach to its diagnosis and treatment.
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