Duodenal and gastric Dieulafoy's lesions in a patient with type 2A von Willebrand's disease

Vascular abnormalities in patients with von Willebrand disease: A scoping review

BACKGROUND

Qualitative or quantitative defects of von Willebrand factor (VWF) such as in von Willebrand disease (VWD) are associated with vascular abnormalities, especially in the gastrointestinal (GI) tract. However, the locations, extent, and natural history of vascular abnormalities in patients with VWD is not well understood. To summarize the existing literature on the topic, we conducted a scoping review of vascular abnormalities in patients with VWD.

METHODS

We searched MEDLINE and EMBASE from inception to September 1, 2020, for studies clinically describing vascular abnormalities in VWD patients. Screening and data extraction was completed independently and in duplicate and each abnormality was documented individually.

RESULTS

After screening, 54 studies that reported patient level data comprising 146 patients were included. Type 2A (39%) and type 3 (14.4%) were the most common VWD subtypes. The most common site of vascular malformation was the GI tract, occurring in 124 patients (84.9%), whereas 18 (12.3%) had non-GI vascular abnormalities and 4 (2.7%) had both GI and non-GI vascular abnormalities. With respect to outcomes, the clinical course was not specified in the majority (55.5%) of patients. Survey and population level data were reported in nine studies, demonstrating vascular abnormalities occurred at higher rates in VWD and that VWD patients are overrepresented among those with those abnormalities.

CONCLUSION

Vascular malformations in patients with VWD occur primarily in the gastrointestinal tract. Type 2A and type 3 VWD are the most common subtypes affected. The clinical treatment and natural history of these abnormalities remains understudied and further research is needed.

Dieulafoy's lesion in the cecum: A rare case report presentation

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.

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Dieulafoy's lesion is a rare entity and is mostly found in the stomach.

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This lesion is an uncommon cause of acute gastrointestinal bleeding.

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Its diagnosis is difficult due to its rarity.

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This case report presents a Dieulafoy's lesion in the colon, an even rarer location.

Dieulafoy's Lesion: Decade-Long Trends in Hospitalizations, Demographic Disparity, and Outcomes

Background

Dieulafoy's lesion is a relatively rare, but potentially life-threatening, condition where a tortuous arteriole, most commonly in the stomach, may bleed and lead to significant gastrointestinal hemorrhage. Limited epidemiological data exist on patient characteristics and the annual number of hospitalizations associated with such lesions. The aim of our study is to determine the inpatient burden of Dieulafoy’s lesion.

Methods

We analyzed the National Inpatient Sample (NIS) database for all subjects with a discharge diagnosis of Dieulafoy's lesion of the stomach, duodenum, and colon using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 537.84 and 569.86 as the primary or secondary diagnosis during the period from 2002 to 2011. Statistical significance of variation in the number of hospital discharges and demographics during the study period was achieved using the Cochrane-Armitage trend test.

Results

In 2002, there were 1,071 admissions with a discharge diagnosis of Dieulafoy's lesion as compared to 7,414 in 2011 (p < 0.0001). Dieulafoy's lesion was found to be most common in the age group of 65-79 years (p < 0.0001). Overall, it was found to be more common in males as compared to females (p = 0.0261). The white race was most commonly affected amongst all the races. The average cost of care per hospitalization increased from $14,992 in 2002 to $25,594 in 2011 (p < 0.0001).

Conclusion

There has been a steady rise in the number of inpatient admissions with Dieulafoy's lesions. Advances in diagnostic techniques likely play a key role in the higher detection rates along with the possible involvement of other unknown factors. Men, in the age group of 65 to 79 years, and Whites were found to have significantly higher admission rates than all other groups, with a significant increase in the cost of care.

Recurrent Gastrointestinal Bleeding from Dieulafoy's Lesions in a Patient with Type 1 von Willebrand Disease: A Rare Association

Von Willebrand disease (vWD) is the most prevalent hereditary bleeding disorder, affecting 0.6-1.3% of the population. While gastrointestinal bleeding from angiodysplasia is a well-known complication of vWD, the same is not true for Dieulafoy's lesions (DLs). We report the case of a 21-year-old black male with type 1 vWD and 2 previous hospital admissions for severe anemia with no visible blood loss. In both episodes, DLs were identified and treated endoscopically, one in the stomach and another in the duodenum. The patient presented to the emergency department in September 2016 with dizziness, fatigue, and again no visible blood loss. He was hemodynamically stable, and laboratory workup showed a hemoglobin level of 3.4 g/dL. After transfusion of packed red blood cells, intravenous iron, and von Willebrand factor/factor VIII concentrate infusions, the patient underwent upper endoscopy and colonoscopy, which were normal. Small-bowel capsule endoscopy showed dark blood and a fresh clot in the proximal jejunum. At this site, push enteroscopy identified a pulsatile vessel with an overlying minimal mucosal defect, consistent with a DL, type 2b of the Yano-Yamamoto classification, which was successfully treated with adrenaline and 2 hemoclips. The patient remains stable after 18 months of follow-up, with a hemoglobin level of 13.2 g/dL. This is a case of recurrent severe occult gastrointestinal bleeding from multiple DL in a young patient with vWD who is otherwise healthy. Three other cases of DL bleeding in the setting of vWD have been reported in the literature, suggesting a possible association between these 2 entities.

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.

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

BACKGROUND

A Dieulafoy's lesion is a submucosal artery that may erode the epithelium and lead to severe hemorrhages. The safety and efficacy of argon plasma coagulation (APC) for the hemostasis of these lesions has not been studied.

OBJECTIVE

To evaluate efficacy of APC alone in the hemostasis of Dieulafoy's lesions.

DESIGN

A retrospective analysis of hemostasis by chart review, with long-term follow-up by outpatient visit or phone interview.

SETTING

An academic hospital with 24-hour endoscopic service availability.

PATIENTS

All patients with acute bleeding from a Dieulafoy's lesion treated with APC.

INTERVENTIONS

Hemostasis was attempted with 2.3-mm APC probes, with settings varying from 40 W to 60 W, according to lesion location.

MAIN OUTCOME MEASUREMENTS

Initial hemostasis, recurrent bleeding, and 30-day mortality rates.

RESULTS

Twenty-three Dieulafoy's lesions were treated with APC, which represented 85% of all such lesions observed. Severe comorbidities and abnormal coagulation were present in 39% and 22%, respectively. Dieulafoy's lesions were located in the upper-GI tract in 20 patients (87%). Active bleeding was found in 20 patients (87%), a nonbleeding visible vessel was found in 2 patients (9%), and a minute mucosal defect below an adherent clot was found in 1 (4%). Initial hemostasis was achieved in all patients, without complications. An injection of an average volume of 3 mL of 1:10,000 epinephrine solution preceded APC in 3 cases for the identification of the bleeding lesion. Recurrent bleeding occurred in a patient after 48 hours; no bleeding-related deaths were observed during a median follow-up of 29 months.

LIMITATIONS

Retrospective study.

CONCLUSIONS

Dieulafoy's lesions can be successfully managed by APC alone.