Hemostasis of Dieulafoy's lesions by argon plasma coagulation (with video)

Ideal strategy for nonvariceal upper gastrointestinal bleeding

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.

Clinical, endoscopic and therapeutic features of bleeding Dieulafoy's lesions: case series and literature review

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.

Outcomes in Severe Upper GI Hemorrhage from Dieulafoy's Lesion with Monitoring of Arterial Blood Flow

BACKGROUND

Dieulafoy's lesion (DL) is a rare but increasingly recognized cause of severe upper GI hemorrhage (SUGIH). There is little consensus regarding the endoscopic approach to management of bleeding from DL.

AIMS

Our purposes were to compare 30-day outcomes of patients with SUGIH from DL with Doppler endoscopic probe (DEP) monitoring of blood flow and guided treatment versus standard visually guided hemostasis (VG).

METHODS

Eighty-two consecutive DL patients with SUGIH were identified in a large CURE Hemostasis database from previous prospective cohort studies and two recent RCTs at two university-based medical centers. 30-day outcomes including rebleeding, surgery, angiography, death, and severe medical complications were compared between the two treatment groups.

RESULTS

40.2% of DL bleeds occurred in inpatients. 43.9% of patients had cardiovascular disease, and 48.7% were taking medications associated with bleeding. For the entire cohort, 41.3% (26/63) of patients treated with VG had a composite 30-day outcome as compared to 10.5% (2/19) of patients treated with DEP (p = 0.017). Rebleeding occurred within 30 days in 33.3% and 10.5% of those treated with VG and DEP, respectively (p = 0.051). After propensity score matching, the adjusted 30-day composite outcome occurred in 39.0% in the VG group compared to 2.6% in the DEP group (p < 0.001). Adjusted 30-day rebleeding occurred in 25.3% in the VG group versus 2.6% in the DEP group (p < 0.001).

DISCUSSION

DL patients with SUGIH were frequently inpatients and had severe cardiovascular comorbidities and recurrent bleeding. Lesion arterial blood flow monitoring and obliteration are an effective way to treat bleeding from DL which reduces negative 30-day clinical outcomes.

Effect of Antithrombotic Therapy on Bleeding after Argon Plasma Coagulation for Gastric Neoplasms

Background/Aims

Postprocedural bleeding is known to be relatively low after argon plasma coagulation (APC) for gastric neoplasms; however, there are few studies proving the effect of antithrombotic agents. This study aimed to analyze the incidence of delayed bleeding (DB) based on antithrombotic agents administered and to identify the risk factors for DB in APC for gastric tumors.

Methods

A total of 785 patients with 824 lesions underwent APC for single gastric neoplasm between January 2011 and January 2018. After exclusion, 719 and 102 lesions were classified as belonging to the non-antithrombotics (non-AT) and AT groups, respectively. The clinical outcomes were compared between the two groups, and we determined the risk factors for DB in gastric APC.

Results

Of the total 821 cases, DB occurred in 20 cases (2.4%) 17 cases in the non-AT group and three cases in the AT group (2.4% vs 2.9%, p=0.728). Multivariate analysis of the risk factors for DB confirmed the following significant, independent risk factors male sex (odds ratio, 7.66; 95% confidence interval, 1.02 to 57.69; p=0.048) and chronic kidney disease (odds ratio, 4.51; 95% confidence interval, 1.57 to 13.02; p=0.005). Thromboembolic events and perforation were not observed in all patients regardless of whether they took AT agents.

Conclusions

AT therapy is acceptably safe in gastric APC because it does not significantly increase the incidence of DB. However, patients with chronic kidney disease or male sex need to receive careful follow-up on the incidence of post-APC bleeding.

A Unique Case of Recurrent Upper Gastrointestinal Bleeding Caused by Two Metachronous Dieulafoy's Lesions: The Role of EUS Evaluation

Introduction

Dieulafoy's lesion (DL) is a rare but important cause of acute, severe, life-threatening, and recurrent upper gastrointestinal bleeding (UGIB). It is frequently difficult to diagnose DL with upper GI endoscopy (UGIE), and endoscopic ultrasonography (EUS) may be valuable. There are only 2 reported bleeding cases caused by two synchronous DL but no reported cases of two metachronous DL.

Case Report

A 28-year-old healthy male presented with acute severe UGIB. UGIE was inconclusive. Systematic EUS mapping identified a gastric DL. After several attempts of EUS-guided hemostasis, DL was marked using a through-the-scope clip and the patient underwent successful transcatheter arterial embolization (TAE). Three years later, a new severe UGIB episode was caused by a second gastric DL in a different location, which was identified and marked by EUS and further successfully treated through TAE. The patient maintained follow-up without evidence of further bleeding.

Discussion/Conclusion

The authors report a unique case of severe, recurrent UGIB caused by two metachronous gastric DL lesions. The importance of systematic EUS scanning for diagnosis, treatment, and follow-up of DL is emphasized, as well as the potential influence in the outcome of other techniques like angiographic embolization.

Can prophylactic argon plasma coagulation reduce delayed post-papillectomy bleeding? A prospective multicenter trial

BACKGROUND AND AIM

Endoscopic post-papillectomy bleeding occurs in 3% to 20% of the cases, and delayed bleeding is also problematic. However, there is no consensus on how to reduce delayed post-papillectomy bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to minimize delayed bleeding and reduce the persistence of residual tumors after endoscopic papillectomy.

METHODS

In a prospective pilot study of patients with benign ampullary tumors, the prophylactic APC group underwent APC at the resection margin following a conventional snaring papillectomy. Then, 24 h later after the papillectomy, all patients underwent a follow-up duodenoscopy to identify post-papillectomy bleeding and were followed up until 12 months. The main outcomes were the delayed (≥24 h) post-papillectomy bleeding rate and the tumor persistence rate.

RESULTS

The delayed post-papillectomy bleeding rate was 30.8% (8/26) in the prophylactic APC group and 21.4% (6/28) in the non-APC group (P = 0.434). The post-procedure pancreatitis rates were 23.1% (6/26) and 35.7% (10/28), respectively (P = 0.310). The rate of tumor persistence did not differ between the two groups at 1 month (12.5% vs 7.4%, P = 0.656), 3 months (4.2% vs 3.7%, P = 1.00), 6 months (8.3% vs 3.7%, P = 0.595), and 12 months (0% vs 3.7%, P = 1.00). There were no procedure-related mortalities or serious complications.

CONCLUSION

Prophylactic APC may not be effective in reducing delayed post-papillectomy bleeding or remnant tumor ablation immediately after conventional papillectomy (Clinical trial registration-cris.nih.go.kr; KCT0001955).

Jejunal Dieulafoy's Lesion: A Systematic Review of Evaluation, Diagnosis, and Management

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.

Gastric vascular abnormalities: diagnosis and management

PURPOSE OF REVIEW

Gastric vascular abnormalities are a well known cause of gastrointestinal bleeding. Due to their recurrent bleeding tendency and potential to cause life-threatening blood loss, gastric vascular abnormalities can result in significant morbidity and cost.

RECENT FINDINGS

There have been novel advances in medical and endoscopic management of gastric vascular lesions. New data suggest that endoscopic band ligation and ablation may be comparable, or even superior, to argon plasma coagulation (APC) for management of gastric antral vascular ectasia (GAVE). A creative, highly sensitive and specific computer-assisted tool has been developed to facilitate reading video capsule endoscopies for the detection of angiodysplasias, paving the way for artificial intelligence incorporation in vascular lesions diagnostics. Over-the-scope clipping is a relatively new technology that shows promising results in controlling bleeding from Dieulafoy's lesions.

SUMMARY

In this article, we will broadly review the management of the most prevalent gastric vascular lesions, focusing on the most recent areas of research.

Life-Threatening Hemoptysis

Life-threatening hemoptysis (LTH) is any amount of hemoptysis that causes significant hemodynamic decompensation or respiratory distress which may lead to death if left untreated. While the amount of hemoptysis that qualifies as massive hemoptysis has continued to be debated, any amount between 100 to 1,000 mL/day is considered significant. Up to 15% cases of hemoptysis are LTH and need urgent life-saving intervention. Understanding of pulmonary vascular anatomy is of paramount importance to manage LTH. The goal of treatment lies in airway protection, appropriate oxygenation, and prevention of exsanguination. Once the airway is stabilized, a quick diagnosis and control of bleeding site is targeted. This chapter highlights current practices and approach to LTH including medical management, bronchoscopic approach, and advanced therapies such as bronchial artery embolization and surgical resection. We review situations, such as bronchiectasis, vascular malformation, diffuse alveolar hemorrhage, and tracheostomy bleed and specific approach to management of these conditions in a systematic and evidence-based manner.

Risk Factors for Rebleeding after Emergency Endoscopic Treatment of Dieulafoy Lesion

Background and Objective: Dieulafoy lesion is a rare, but life-threatening, cause of gastrointestinal hemorrhage, and endoscopic therapy is the preferred first-line treatment. The present study aims to analyze the risk factors for rebleeding after endoscopic hemostasis of gastroduodenal Dieulafoy lesion. Methods. A retrospective review of patients with Dieulafoy lesion who developed acute gastrointestinal bleeding and were treated primarily with endoscopic therapy from September 2014 to April 2019 was conducted. Results. A total of 133 patients with Dieulafoy lesion were included in the present study. The mean age of these patients was 56.05 ± 16.58 years, and 115 patients were male. Among these 133 patients, 26 patients developed rebleeding within 30 days of endoscopic therapy. The 30-day rebleeding rate for pure injection therapy (epinephrine, cyanoacrylate, or lauromacrogol injection alone), nonpure injection therapy (argon plasma coagulation, band ligation, and hemoclip application alone), and combination therapy (combination of any >2 methods) was 45.2%, 12.8%, and 11%, respectively. In the univariable analysis, endoscopic treatment, prothrombin time, gender, Rockall score, and leukocyte count were the risk factors for rebleeding. In the multivariable analysis, pure injection endoscopic treatment, white blood cells (>10 × 10⁹/L), and prothrombin time >12 seconds were the independent risk factors for rebleeding. Conclusion. Patients who undergo pure injection endoscopic treatment and have a high leukocyte count (>10 × 10⁹/L) or elevated prothrombin time (>12 seconds) have an increased risk of rebleeding within 30 days after endoscopic treatment for gastroduodenal Dieulafoy lesion. Combined endoscopic treatment is the most effective therapy to prevent rebleeding in gastroduodenal Dieulafoy lesion.

Massive Gastrointestinal Bleeding from a Jejunal Dieulafoy Lesion: An Extraordinary Presentation

We present an atypical and rare case of a previously healthy 27-year-old male who presented with acute onset of abdominal pain, bloody diarrhea, and syncope. At the Emergency Department, vital signs were stable with no signs of shock. Physical examination revealed diffuse tenderness of the abdomen and cherry red blood was noted upon rectal examination. Blood tests showed marked leukocytosis without anemia. Sigmoidoscopy was performed which revealed hematochezia with no obvious site of bleeding. The patient was admitted to the hospital with a working diagnosis of dysentery and received supportive care. During the following days, blood tests revealed an ongoing decline of hemoglobin levels which necessitated a new workup of gastrointestinal bleeding. Investigation modalities including upper and lower endoscopies as well as angiography failed to demonstrate a bleeding site. Scintigraphy, which was performed next, demonstrated an increased radiotracer activity in the right abdomen consistent with small bowel bleeding. Following these results, the patient underwent urgent laparotomy and surgical resection was performed. The histopathological findings were consistent with a Dieulafoy lesion. This case illustrates the importance of the complementary role of various modalities in locating the bleeding site along the gastrointestinal tract.

Devices for endoscopic hemostasis of nonvariceal GI bleeding (with videos)

BACKGROUND

Endoscopic intervention is often the first line of therapy for GI nonvariceal bleeding. Although some of the devices and techniques used for this purpose have been well studied, others are relatively new, with few available outcomes data.

METHODS

In this document, we review devices and techniques for endoscopic treatment of nonvariceal GI bleeding, the evidence regarding their efficacy and safety, and financial considerations for their use.

RESULTS

Devices used for endoscopic hemostasis in the GI tract can be classified into injection devices (needles), thermal devices (multipolar/bipolar probes, hemostatic forceps, heater probe, argon plasma coagulation, radiofrequency ablation, and cryotherapy), mechanical devices (clips, suturing devices, banding devices, stents), and topical devices (hemostatic sprays).

CONCLUSIONS

Endoscopic evaluation and treatment remains a cornerstone in the management of nonvariceal upper- and lower-GI bleeding. A variety of devices is available for hemostasis of bleeding lesions in the GI tract. Other than injection therapy, which should not be used as monotherapy, there are few compelling data that strongly favor any one device over another. For endoscopists, the choice of a hemostatic device should depend on the type and location of the bleeding lesion, the availability of equipment and expertise, and the cost of the device.

New insights on an old medical emergency: non-portal hypertension related upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition and is the most common medical emergency managed by gastroenterologists. Despite being one of the most antique medical problems, recent studies have been slowly changing the management of these patients, which should nowadays include not only initial resuscitation, but also risk stratification, pre-endoscopic therapy, endoscopy treatment, and post-procedure care. The aim of this paper is to review the extended approach to the patient with non-portal hypertension related UGIB.

Life-threatening bleeding from gastric dieulafoy's lesion in a pregnant woman with hellp syndrome: a case report and literature review

BACKGROUND

Dieulafoy's lesion (DL) is one of the rare causes of upper gastrointestional bleeding. This disease is characterized by small sub-mucosal arteriole that eroded the stomach mucosa and cause severe upper GI bleeding without obvious ulceration. The most common location is fundus area of stomach and usually affects patients over 50 years of age with multiple comorbidities.

CASE PRESENTATION

We report a case of life-threatening bleeding from DL during late pregnancy 31 weeks. Hemoclips were used twice through upper endoscopy with successful hemostasis. Unfortunately, she developed HELLP syndrome diagnosed 5 days after the GI bleeding was stopped. Her pregnancy had to be terminated with delivery of a premature infant. She recovered from her illness and discharged from hospital uneventfully. There is no current report in literature of DL in pregnant woman subsequently suffered HELLP syndrome.

CONCLUSION

Endoscopic hemoclip application is an effective technique in the treatment of upper GI bleeding from DL. For this patient, laparoscopic surgery or combination therapy before pregnancy may have been a suitable treatment on preventing rebleeding.

Dieulafoy's Lesion of the Anal Canal: A Rare Cause of Lower Gastrointestinal Bleeding

BACKGROUND Dieulafoy's lesion of the anal canal is an uncommon cause of lower gastrointestinal bleeding due to rupture of a submucosal artery. This could be an under-recognized cause of hemorrhagic shock in rare cases. CASE REPORT We present 2 cases admitted with bleeding per rectum and hemorrhagic shock, and both were diagnosed as Dieulafoy's lesion of the anal canal on sigmoidoscopy. One case was treated surgically and the second was managed endoscopically. CONCLUSIONS Dieulafoy's lesion of the anal canal can be a source of massive lower gastrointestinal bleeding. Initial anoscopy or sigmoidoscopy might miss such a lesion. Proper visualization helps not only the diagnosis, but also the provision of therapeutic intervention in the same setting.

Culprit for recurrent acute gastrointestinal massive bleeding: “Small bowel Dieulafoy’s lesions” - a case report and literature review

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.

Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis

AIM: To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy’s lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis.

METHODS: Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: “alcoholic liver disease”, “alcoholic hepatitis”,“ alcoholic cirrhosis”, “cirrhosis”, “liver disease”, “upper gastrointestinal bleeding”, “non-variceal upper gastrointestinal bleeding”, “PUD”, ‘‘DL’’, ‘‘Mallory-Weiss tear”, and “MWS’’.

RESULTS: While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population.

CONCLUSION: Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.

Do We Perform a Perfect Endoscopic Hemostasis Prophylactically with Argon Plasma Coagulation in Colonic Endoscopic Mucosal Resection?

BACKGROUND

Submucosal injection for endoscopic mucosal resection (EMR) may effect performing the prophylactic argon plasma coagulation (APC) of non-bleeding visible vessels on ulcer crater.

AIMS

The purpose of this study was to evaluate the clinical features of visible vessels in iatrogenic ulcers over time after prophylactic APC in colonic EMR.

PATIENTS AND METHODS

This study was designed as a prospective study. Between August and November 2013, a total of 40 patients who were admitted underwent prophylactic APC for non-bleeding visible vessels after colonic EMR. After confirming whether visible vessels were completely coagulated or not, the number of visible vessels in ulcers was counted over a specific time period, e.g. 1, 3, 5, or 7 min.

RESULTS

The mean number of visible vessels was significantly higher at 5 min (0.85 ± 1.14) after EMR with prophylactic APC compared to 1 and 3 min (1 min: 0.28 ± 0.60, P < 0.001; 3 min: 0.65 ± 0.87, P = 0.02) and there was no significant difference between 5 and 7 min (P = 0.31). Multivariate analysis showed that the size of the iatrogenic ulcer after EMR was associated with the occurrence of visible vessels (ulcer size >1 vs. ≤0.5 cm: OR 27.32, 95% CI 2.86-infinity).

CONCLUSIONS

A 5-min observation of the ulcer may be advantageous for the assessment of visible vessels after performing colonic EMR with prophylactic APC, and large (>1 cm) iatrogenic ulcers were associated with the occurrence of visible vessels after colonic EMR.

Predictors of Rebleeding in Upper Gastrointestinal Dieulafoy Lesions

BACKGROUND/AIMS

Dieulafoy lesions (DLs) are a rare but significant cause of upper gastrointestinal bleeding. We aimed to define the clinical significance of rebleeding and identify the predictors of rebleeding and mortality in upper gastrointestinal Dieulafoy lesions (UGIDLs).

METHODS

Patients diagnosed with UGIDLs between January 2004 and June 2013 were retrospectively evaluated. Multivariate logistic regression analyses were performed to define the predictors of rebleeding and mortality in patients with UGIDLs.

RESULTS

The study group consisted of 81 male and 36 female patients. Primary hemostasis was achieved in 115 out of 117 patients (98.3%) with various endoscopic therapies. Rebleeding occurred in 10 patients (8.5%). The mortality rate was significantly higher in patients with rebleeding than in those without rebleeding (30.0% vs. 4.7%, p=0.020). Multivariate logistic regression analysis revealed that kidney disease (p=0.006) and infection (p=0.005) were significant predictors of rebleeding in UGIDLs and that kidney disease (p=0.004) and platelet count (p=0.013) were significant predictors of mortality.

CONCLUSIONS

Rebleeding has an important prognostic significance in patients with UGIDLs. Kidney disease and infection are major predictors of rebleeding and mortality in patients with UGIDLs.

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

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

Unusual Causes of Upper Gastrointestinal Bleeding

Upper gastrointestinal (GI) bleeding is an important clinical condition managed routinely by endoscopists. Diagnostic and therapeutic options vary immensely based on the source of bleeding and it is important for the gastroenterologist to be cognizant of both common and uncommon etiologies. The focus of this article is to highlight and discuss unusual sources of upper GI bleeding, with a particular emphasis on both the clinical and endoscopic features to help diagnose and treat these atypical causes of bleeding.

Risk Factors for Dieulafoy Lesions in the Upper Gastrointestinal Tract

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.

Bleeding "Dieulafoy's-like" lesion resembling the duodenal papilla: a case report

Introduction

Dieulafoy’s lesion is an uncommon but important cause of gastrointestinal bleeding in which hemorrhage occurs from a pinpoint, non-ulcerated arterial lesion. DLs are usually located in the stomach, most commonly in people between the ages of 50 and 70 years. In this report, we describe a teenage patient with an unusual presentation of a bleeding duodenal Dieulafoy’s-like lesion that resembled the duodenal papilla.

Case presentation

An 18-year-old Pakistani woman presented to our emergency department with hematemesis of 6 hours’ duration. Her past medical history was unremarkable. A nasogastric aspirate was negative for blood. The patient’s hemoglobin was found to be 4g/dl. She was resuscitated with intravenous fluids and blood transfusion. An esophagogastroduodenoscopy was performed, which revealed swelling in the first part of the duodenum, the initial appearance of which suggested that it was an abnormally placed or accessory papilla. There was a small, <3–mm opening on the lesion that resembled the biliary or pancreatic orifice. On gentle manipulation with a catheter, blood spurted from the swelling area, and a vessel was visible. Adrenaline was used for hemostasis. After hemostasis was achieved, it became clear that the lesion was most consistent with a Dieulafoy’s-like lesion and not a papilla. Band ligation was then performed, and the patient did not develop any complications and did not have any further episodes of bleeding. The patient was eventually discharged to home in stable condition.

Conclusions

This case report highlights the importance of considering a DL as a cause of small-bowel hemorrhage and recognizing its potential resemblance to the papilla. Although the endoscopic diagnostic criteria for a Dieulafoy’s lesion have been described in great detail, there is a paucity of literature describing a Dieulafoy’s lesion or a similar lesion resembling the duodenal papilla.

Endoscopic Management of Dieulafoy's Lesion

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.

Rectal dieulafoy lesions: a rare etiology of chronic lower gastrointestinal bleeding

Dieulafoy lesion is rarely seen, yet it can be life-threatening. This lesion makes up to 1-2% of gastrointestinal bleedings and must definitely be considered in gastrointestinal bleedings whose source cannot be identified. In this case study, the 75-year-old woman was suffering from active, fresh, and massive rectal bleeding. Colonoscopy was applied in order to find out the source of bleeding. In the typical endoscopic appearance of the lesion a single round mucosal defect in the rectum and arterial bleeding were observed. To procure hemostasis, epinephrine was injected into the lesion and the bleeding vein was sutured.

Management of upper gastrointestinal bleeding emergencies: evidence-based medicine and practical considerations

Acute upper gastrointestinal (GI) bleeding remains one of the most common encounters in emergency medicine. The increased use of non-steroid anti-inflammatory drugs by the general population and the increased prescription of anti-platelet agents and anti-coagulants after cardiovascular interventions and for prevention of cerebral vascular accidents may have aggravated the situation. Significant progress has been made in the past decade or so in the non-surgical management of acute upper GI bleeding emergencies. This article will review the current standard treatment of the most common upper GI bleeding emergencies in adults as supported by evidence-based medicine with practical considerations from the authors' own practice experience.

Non-variceal gastrointestinal bleeding in patients with liver cirrhosis: a review

BACKGROUND

Non-variceal gastrointestinal (NVGI) bleeding in cirrhosis may be associated with life-threatening complications similar to variceal bleeding.

AIM

To review NVGI bleeding in cirrhosis.

METHODS

MEDLINE, Scopus, and ISI Web of Knowledge were searched, using the textwords "portal hypertensive gastropathy," "gastric vascular ectasia," "peptic ulcer," "Dieulafoy's," "Mallory-Weiss syndrome," "portal hypertensive enteropathy," "portal hypertensive colopathy," "hemorrhoids," and "cirrhosis."

RESULTS

Portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE) are gastric lesions that most commonly present as chronic anemia; acute upper GI (UGI) bleeding is a rare manifestation. Management of PHG-related bleeding is mainly pharmacological, whereas endoscopic intervention is favored in GVE-related bleeding. Shunt therapies or more invasive techniques are restricted in refractory cases. Despite its high incidence in cirrhotic patients, peptic ulcer accounts for a relatively small proportion of UGI bleeding in this patient population. However, in contrary to general population, the pathogenetic role of Helicobacter pylori infection remains questionable. Finally, other causes of UGI bleeding include Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids. However, the vast majority of studies are case reports and, therefore, the incidence, diagnosis, and risk of bleeding remain undefined. Endoscopic interventions, shunting procedures, and surgical techniques have been described in this setting.

CONCLUSIONS

The data on NVGI bleeding in liver cirrhosis are surprisingly scanty. Large, multicenter epidemiological studies are needed to better assess prevalence and incidence and, most importantly, randomized studies should be performed to evaluate the success rates of therapeutic algorithms.

Prognostic factors for recurrence of gastrointestinal bleeding due to Dieulafoy's lesion

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.

Upper gastrointestinal dieulafoy's lesions and endoscopie treatment: first report from a mexican centre

The aim was to evaluate the initial success, rebleeding rate, need for emergent surgery, and mortality rates of patients with Dieulafoy's lesion (DL) and endoscopic treatment (ET). Patients with DL from a tertiary center were included. We included 20 patients with follow-up of 90 (60-550) days. The lesser curvature was the most common localization. Initial success, rebleeding, and emergent surgery requirement were observed in 90%, 10%, and 15%, respectively. No objective variables were related with response to ET. In conclusion, ET is secure and useful in patients with DL and it must be considered as the first-line treatment modality.

Differential diagnosis of upper gastrointestinal bleeding proximal to the ligament of Trietz

Upper gastrointestinal bleeding (UGIB) is an important medical problem for patients and the medical system. The causes of UGIB are varied and their accurate identification guides appropriate management. The major cause of UGIB is peptic ulcer disease, for which Helicobacter pylori and nonsteroidal antiinflammatory drug use are major risk factors. Lesser causes include Dieulafoy lesion, gastric antral vascular ectasia, hemobilia, aortoenteric fistulas, and upper gastrointestinal tumors. Awareness of causes and management of UGIB should allow physicians to treat their patients more effectively.

Dieulafoy's lesion: current trends in diagnosis and management

BACKGROUND

Dieulafoy's lesion is a relatively rare, but potentially life-threatening, condition. It accounts for 1-2% of acute gastrointestinal (GI) bleeding, but arguably is under-recognised rather than rare. Its serious nature makes it necessary to include it in the differential diagnosis of obscure GI bleeding. The aim of this study was to review the current trends in the diagnosis and management of Dieulafoy's lesion.

MATERIALS AND METHODS

Using Medline, a literature search was performed for articles published in English, using the search words 'Dieulafoy'(s)' and 'gastrointestinal bleeding'. All retrieved papers were analysed and the findings are summarised in this review.

RESULTS

There is no consensus on the treatment of Dieulafoy's lesions. Therapeutic endoscopy can control the bleeding in 90% of patients while angiography is being accepted as a valuable alternative to endoscopy for inaccessible lesions. Currently, surgical intervention is kept for failure of therapeutic endoscopic or angiographic interventions and it should be guided by pre-operative localisation.

CONCLUSIONS

Advances in endoscopy have increased the detection of Dieulafoy's lesions and decreased the mortality from 80% to 8.6%. There are recent encouraging reports on the successful use of laparoscopic surgery in managing symptomatic Dieulafoy's lesions.

Dieulafoy's lesion: current trends in diagnosis and management

BACKGROUND

Dieulafoy's lesion is a relatively rare, but potentially life-threatening, condition. It accounts for 1-2% of acute gastrointestinal (GI) bleeding, but arguably is under-recognised rather than rare. Its serious nature makes it necessary to include it in the differential diagnosis of obscure GI bleeding. The aim of this study was to review the current trends in the diagnosis and management of Dieulafoy's lesion.

MATERIALS AND METHODS

Using Medline, a literature search was performed for articles published in English, using the search words 'Dieulafoy'(s)' and 'gastrointestinal bleeding'. All retrieved papers were analysed and the findings are summarised in this review.

RESULTS

There is no consensus on the treatment of Dieulafoy's lesions. Therapeutic endoscopy can control the bleeding in 90% of patients while angiography is being accepted as a valuable alternative to endoscopy for inaccessible lesions. Currently, surgical intervention is kept for failure of therapeutic endoscopic or angiographic interventions and it should be guided by pre-operative localisation.

CONCLUSIONS

Advances in endoscopy have increased the detection of Dieulafoy's lesions and decreased the mortality from 80% to 8.6%. There are recent encouraging reports on the successful use of laparoscopic surgery in managing symptomatic Dieulafoy's lesions.

Endoscopic hemostasis techniques for upper gastrointestinal hemorrhage: A review

Upper gastrointestinal hemorrhage (UGIH) is an urgent disease that is often encountered in daily medical practice. Endoscopic hemostasis is currently indispensable for the treatment of UGIH. Initially, when UGIH is suspected, a cause of UGIH is presumed from the medical interview and physical findings. After ample primary treatment, urgent endoscopy is performed. Many methods of endoscopic hemostasis are in wide use, including hemoclip, injection and thermo-coagulation methods. Although UGIH develops from a wide variety of diseases, such as esophageal varices and gastric and duodenal ulcer, hemostasis is almost always possible. Identification of the causative diseases, primary treatment and characteristic features of endoscopic hemostasis are needed to allow appropriate treatment.

Clinical and endoscopic analysis of gastric Dieulafoy’s lesion

AIM: To investigate the incidence, location, clinical presentation, diagnosis and effectiveness of endoscopic treatment of gastric Dieulafoy’s lesion (DL) in China.

METHODS: All patients who received emergency upper gastrointestinal (GI) endoscopy due to gastric DL from February 2000 to August 2008 at GI endoscopy center of Renmin Hospital of Wuhan University were included in this study. The clinical presentation, medical history, location and characteristics of DL methods and effectiveness of therapy of patients with DL were retrospectively analysed by chart reviews. Long-term follow-up data were collected at outpatient clinics or telephone interviews.

RESULTS: Fifteen patients were diagnosized with DL, which account for 1.04% of the source of bleeding in acute non-variceal upper GI bleeding. Common comorbidities were found in one patient with hypertension and diabetic mellitus. Hemoclip or combined therapy with hemoclip produced primary hemostasis in 92.8% (13/14) of patients.

CONCLUSION: DL is uncommon but life-threatening in China. Hemoclip proved to be safe and effective in controlling bleeding from DL.

Endoscopic treatment of dieulafoy lesions and risk factors for rebleeding

BACKGROUND/AIMS

Dieulafoy lesions are an important cause of upper gastrointestinal bleeding. The purpose of this study was to assess the efficacy of endoscopic treatment for these lesions and to identify the possible predictive factors for rebleeding associated with clinical and endoscopic characteristics.

METHODS

Records from 44 patients admitted with Dieulafoy bleeding between January 2006 and December 2007 were reviewed. We retrospectively analyzed the clinical and endoscopic findings and then correlated the rebleeding risk factors with Dieulafoy lesions.

RESULTS

Primary hemostasis was achieved by endoscopic treatment in 39 patients (88.6%). There were no significant differences between the rebleeding and non-rebleeding groups with respect to age, gender, initial hemoglobin levels, presence of shock, concurrent disease, location of bleeding, or initial hemostatic treatment methods. However, the use of non-steroidal anti-inflammatory drugs or anticoagulants (p=0.02) and active stages in the Forrest classification (p<0.01) were risk factors for rebleeding after endoscopic therapy.

CONCLUSIONS

Endoscopic therapy is effective and safe for treating Dieulafoy lesions, and it has both short- and long-term benefits. Early identification of risk factors such as the use of non-steroidal anti-inflammatory drugs or anticoagulants and the Forrest classification of bleeding predict the outcome of Dieulafoy lesions.

Endoscopic treatment of dieulafoy lesions and risk factors for rebleeding

BACKGROUND/AIMS

Dieulafoy lesions are an important cause of upper gastrointestinal bleeding. The purpose of this study was to assess the efficacy of endoscopic treatment for these lesions and to identify the possible predictive factors for rebleeding associated with clinical and endoscopic characteristics.

METHODS

Records from 44 patients admitted with Dieulafoy bleeding between January 2006 and December 2007 were reviewed. We retrospectively analyzed the clinical and endoscopic findings and then correlated the rebleeding risk factors with Dieulafoy lesions.

RESULTS

Primary hemostasis was achieved by endoscopic treatment in 39 patients (88.6%). There were no significant differences between the rebleeding and non-rebleeding groups with respect to age, gender, initial hemoglobin levels, presence of shock, concurrent disease, location of bleeding, or initial hemostatic treatment methods. However, the use of non-steroidal anti-inflammatory drugs or anticoagulants (p=0.02) and active stages in the Forrest classification (p<0.01) were risk factors for rebleeding after endoscopic therapy.

CONCLUSIONS

Endoscopic therapy is effective and safe for treating Dieulafoy lesions, and it has both short- and long-term benefits. Early identification of risk factors such as the use of non-steroidal anti-inflammatory drugs or anticoagulants and the Forrest classification of bleeding predict the outcome of Dieulafoy lesions.

Treatment of gastrointestinal diseases with second-generation argon plasma coagulation: an analysis of 260 cases

AIM: To investigate the safety and efficacy of the second-generation argon plasma coagulation (VIO APC) for gastrointestinal diseases.

METHODS: During 2007-09-14/2008-10-22, 260 patients were treated using VIO APC in a total of 289 sessions. For various indications, the new VIO APC device was used. Safety and efficacy of VIO APC were recorded after each individual treatment session.

RESULTS: The mean number of treatment sessions required using VIO APC in various indications was 1.11 ± 0.31. In the palliative treatment of gastric adenocarcinoma, it was 2.50; in endoscopic hemostasis, it was 1.23; in the treatment of colorectal polypi, it was 1.15, in the treatment of upper gastrointestinal polypi, it was 1.03, in the management of self-expand stent overgrowth or tumor stenosis, it was 1.17; in the ablation of Barrett's esophagus, it was 1.13; in the ablation of gastric dysplasia, gastritis verrucosa, gastric xanthelasma and gastric or duodenal liparomphalus, only 1 session was needed. Minor complications (pain, dysphagia/odynophagia, asymptomatic gas accumulation in the intestinal wall) were observed in 10.1%-20% sessions, but no major complications (hemorrhage, perforation, stenosis) were observed.

CONCLUSION: VIO APC is effective and safe for various gastrointestinal conditions. It can be widely applied to daily endoscopic treatment.

Argon plasma coagulation under magnifying chromoendoscopy for gastric premalignant lesions: an analysis of 90 cases

AIM: To investigate the effects and clinical value of argon plasma coagulation (APC) on gastric premalignant lesions under magnifying chromoendoscopy (MCE).

METHODS: A total of 90 cases with gastric premalignant lesions underwent argon plasma coagulation under magnifying chromoendoscopy using Fujinon EG-590ZW magnifying endoscope in combination with methylene blue staining. The changes of microstructures after treatment were studied and compared with histopathology.

RESULTS: Six months after argon plasma coagulation treatment, microstructures of gastric mucosa in 90 cases with intestinal metaplasia and dysplasia were regenerated from type E, F to type C or D (86.7%, 6.7%), and the abnormal hyperplasia blood capillary disappeared. Histopathological tissues changed into active inflammation (85.6%) or atrophic inflammation (8.9%). The ablation rates of microstructures (type E and F) and histopathology (intestinal metaplasia and dysplasia) were 93.0% and 94.4%, respectively.

CONCLUSION: Argon plasma coagulation is a safe and effective method in the treatment of gastric premalignant lesions.

Argon plasma coagulation therapy

PURPOSE OF REVIEW

To give a summary of recent advances in argon plasma coagulation (APC) therapy in gastroenterology.

RECENT FINDINGS

APC has gained importance in gastrointestinal endoscopy during the last decade, and APC technology has improved over time. Recently published studies, mainly consisting of case series, have shown that APC can be used effectively in various forms of gastrointestinal disorders. The complication rates observed during clinical application are low.

SUMMARY

APC can be considered as a well tolerated and effective treatment approach in endoscopy. Further clinical trials including a comparison of APC to other treatment modalities as well as long-term follow-up after APC treatment are required to clarify the relative value of APC in gastroenterology.

Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy

Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.