Dieulafoy's lesion: management and long-term outcome

Role of imaging and endovascular radiology in endoscopically missed Dieulafoy’s lesion of stomach – A case report with review

Dieulafoy’s lesion is an uncommon cause of life-threatening gastrointestinal bleed from a dilated and tortuous submucosal artery. With the advent of endoscopy-guided intervention, the mortality of the condition has reduced significantly from 80 to 8%. Imaging plays a vital role in diagnosing them in endoscopically negative cases. Endovascular management can also be offered for unidentified lesions or failed endoscopic treatment. We report a middle-aged male with acute hematemesis where endoscopy was unable to reveal the source of the bleed. Contrast CT detected the lesion, which was embolised by endovascular route. The clinical details, imaging appearance and treatment of this uncommon lesion is presented.

Case report: fatal bleeding from a duodenal ulcer-Dieulafoy's lesion?

A 46-year-old man was admitted to the hospital by ambulance due to syncope. A standard blood screening showed a normal Hb value. The man had known hemorrhoids and a single fresh rectal bleeding earlier at home. On the following morning, the patient suddenly required resuscitation within a few minutes and subsequently died. Autopsy revealed a fatal hemorrhage with blood loss in the stomach and small and large intestines and a mucosal defect of the duodenum. After autopsy, the question arose whether the cause of death might have been a rare Dieulafoy’s lesion—aim of this case report was to clarify the diagnosis.

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.

Tödliches Dieulafoy-Ulkus

Nach einem Schlaganfall wurde ein 51 Jahre alter Mann in eine Rehaklinik verlegt. Gemäß klinischen Angaben soll sich dort eine Sepsis entwickelt haben. Aufgrund eines plötzlichen Bewusstseinsverlustes wurde der Patient umgehend in die nächstgelegene Klinik verbracht, wo er trotz umgehender Behandlung verstarb. Da die Ehefrau Vorwürfe gegen das Personal der Rehaklinik erhob, wurde eine rechtsmedizinische Obduktion in Auftrag gegeben.

Im Rahmen der Obduktion fielen große Mengen flüssigen Blutes im Magen sowie im oberen Gastrointestinaltrakt auf, sodass bereits autoptisch ein inneres Verbluten als Todesursache definiert wurde. Als Blutungsquelle kam ein makromorphologisch auffälliges, eröffnetes Gefäß im Magenfundus in Betracht. Die sichere Diagnose eines tödlichen Dieulafoy-Ulkus konnte jedoch erst nach histologischer Begutachtung erfolgen. Definierend für diesen Befund ist eine kaliberpersistente Arterie in der Submukosa ohne pathologische Veränderungen. Bei sicherer Diagnose kann dieser Befund einen plötzlichen Tod aus natürlicher Ursache darstellen. Da das Ulkus im gesamten gastrointestinalen Trakt vorkommen kann, ist bei relevantem Blutverlust und unklarer Blutungsquelle neben der genauen Inspektion eine histologische Aufarbeitung möglicher Blutungsquellen unerlässlich. Damit die Kriterien eines Dieulafoy-Ulkus beurteilt werden können, sollte neben einer HE(Hämatoxylin-Eosin)-Färbung mindestens eine EvG(Elastica-van-Gieson)-Färbung durchgeführt werden. Nur dann können alternative Entstehungsmöglichkeiten ausgeschlossen werden, welche aus forensischer Sicht möglicherweise hätten verhindert werden können.

Dieulafoy lesion in a Hartmann stump

A 70-year-old man underwent laparoscopic anterior resection for sigmoid carcinoma, and on postoperative day 4, he required an emergency Hartmann procedure for bowel ischemia and anastomotic leakage. Five days after the emergency procedure, there was a massive hemorrhage through the anus that appeared in the abdominal drain. During exploration, the origin of the bleeding could not be found, and the rectal stump was closed over a urinary Foley catheter (with an inflated balloon) with the help of a purse-string suture. In the intensive care unit, massive hematochezia continued. Emergency transanal colonoscopy to the Hartmann stump found the rectum full of clotted blood. Active pulsatile arterial bleeding of a rectal Dieulafoy lesion was detected. After endoscopic hemostasis efforts failed, bleeding was stopped successfully by transanal suturing. The patient was discharged without any other problems, and no recurrent bleeding occurred during the 18-month follow-up. Here, we report a rectal Dieulafoy lesion in a Hartmann stump for the first time.

Dieulafoy Lesion: Predictive Factors of Early Relapse and Long-Term Follow-Up

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.

The efficiency of endoclips in maintaining the gastrointestinal bleeding-related Dieulafoy's lesion

BACKGROUND

Dieulafoy's lesion (DL) is a relatively uncommon medical condition characterized by a large tortuous arteriole in the submucosa of any part of gastrointestinal (GI) tract wall that bleeds via erosion likely caused in the submucosal surface by protrusion of the pulsatile arteriole. Compared with other endoscopic hemostatic techniques, clipping alone for DL is limited.

AIMS

The aim of the present case series study is to identify common clinical and endoscopic features, rates of occurrence, to review the outcome of endoscopic management of upper GI tract DL, and to illustrate the use and the efficiency of endoclips in maintaining the GI bleeding due to DL.

PATIENTS AND METHODS

This case series was conducted at Department of Gastroenterology, Dıskapı Yıldırım Beyazıt Educational and Research Hospital. The patients who were admitted to the emergency department of Dıskapı Yıldırım Beyazıt Educational and Research Hospital underwent gastrointestinal system (GIS) endoscopy between 2008 and 2013 and were assessed retrospectively. Five cases of GI bleeding related to DL were given endoscopic treatment with hemoclip application. Clinical data, endoscopic findings, and the effects of the therapy were evaluated.

RESULTS

The median number of endoscopic hemoclips application in first endoscopy was 4 (2-9). Rebleeding developed in all patients who had hemoclips applied. Re-endoscopy was performed in three of these patients, which controlled the bleeding. Two patients were transferred to surgery.

CONCLUSIONS

Combination of endoscopic injection and mechanical therapies seems a suitable method for maintaining upper GIS bleeding due to DL. Also, further studies are needed to better define the best endoscopic approach for the treatment of DL.

Progress in treatment of bleeding in Dieulafoy's disease by endoscopic metal titanium clamp

Dieulafoy's disease is one of the rare causes of upper gastrointestinal bleeding. Since its pathogenesis is different from that of common gastrointestinal bleeding, traditional acid suppression method has a poor therapeutic effect. Over the past decade, endoscopic hemostatic technologies have developed rapidly and have been vigorously recommended as the preferred method to replace surgery. Among them, endoscopic metal clamp stops bleeding quickly, has a definite curative effect distinctly, and is increasingly advocated by clinicians. However, large-sample studies on endoscopic metal titanium clamp in the treatment of bleeding in Dieulafoy disease are still lacking. This paper systematically reviews the recent advances in the treatment of bleeding in Dieulafoy's disease by endoscopic metal titanium clamp.

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.

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.

ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding

Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.

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.

Outcomes in Dieulafoy's Lesion: A 10-Year Clinical Review

BACKGROUND

Dieulafoy's lesion (DL) is a rare, but serious cause of gastrointestinal bleeding, most frequently treated with endoscopic therapy. We examined 10 years of data to assess clinical outcomes in DL.

METHODS

Data were captured by retrospective chart review to assess 109 patients treated endoscopically for bleeding DL from 2003 to 2013. Data collected included demographics, comorbidities, presenting symptoms, risk factors, laboratory values, treatment, rebleeding, surgical intervention, and mortality. Treatment success, rebleeding rates, and mortality were the main outcomes measured.

RESULTS

Of 109 patients with bleeding DL, 54 % were male and 46 % were female. Mean age was 79.4 years; mean follow-up duration was 40.4 ± 35.8 months. Clinical presentation for most patients included melena, hematemesis, hematochezia, and/or anemia with approximately one-third of patients also experiencing anemia-related symptoms. Most lesions were located in stomach (53 %) followed by duodenum/jejunum (33 %) and large intestine (13 %). Thermal endoscopic therapy (70 %) was the most frequently performed procedure followed by injection (46 %) and mechanical (46 %) endoscopy therapy at equal frequency. Combined therapy (51 %) was common, with over half of patients undergoing two or more endoscopic modalities simultaneously. The finding that only 11 (10 %) patients had rebleeding from DL suggests that endoscopic therapy resulted in successful hemostasis in the remaining 98 patients (90 %) during follow-up. Mortality related to DL was low.

CONCLUSIONS

Most patients with bleeding DL presented with symptoms of acute bleeding, but many had symptoms suggesting subacute or chronic bleeding. Endoscopic therapy resulted in successful hemostasis in approximately 90 % of patients during follow-up. Rebleeding was rare and particularly uncommon in those treated with combined endoscopic therapy.

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.

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.

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.

Hemostatic efficacy and clinical outcome of endoscopic treatment of Dieulafoy's lesions: comparison of endoscopic hemoclip placement and endoscopic band ligation

BACKGROUND

The most suitable mechanical endoscopic hemostasis for a bleeding Dieulafoy's lesion (DL) is not yet well established.

OBJECTIVE

To compare the hemostatic efficacy and clinical outcome of endoscopic hemoclip placement (EHP) and endoscopic band ligation (EBL).

DESIGN

Retrospective, single-center study.

SETTING

A tertiary-care referral university hospital.

PATIENTS

Sixty-six patients who received mechanical endoscopic hemostasis for bleeding DLs.

INTERVENTIONS

Endoscopic hemostasis.

MAIN OUTCOME MEASUREMENT

Primary hemostasis and rebleeding rates.

RESULTS

DLs accounted for 3.8% of cases of acute nonvariceal upper GI bleeding during the study period. Active bleeding from DLs was noted in 34 patients (51.5%). EHP and EBL were performed as a method of endoscopic hemostasis in 34 and 32 patients, respectively. There were no significant differences between the 2 groups with respect to baseline characteristics (except comorbidities) and endoscopic features of DLs. Primary hemostasis was achieved in all 66 patients (100%). There were 6 cases of recurrent bleeding: 5 (14.7%) and 1 (3.1%) in the EHP and EBL groups, respectively. Secondary hemostasis was achieved with endoscopic treatment and angiographic embolization in 5 patients and 1 patient, respectively, and no patients required surgery. The mean procedure time of endoscopic hemostasis was significantly longer in the EHP group (19.1 vs 11.5 minutes, P = .015). There was no bleeding-related mortality.

LIMITATIONS

Retrospective analysis.

CONCLUSIONS

Both EHP and EBL are suitable for the treatment of bleeding DLs. EBL can be used as an initial hemostatic method for bleeding DLs because of a favorable clinical outcome comparable to that with EHP and a shorter procedure time.

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.

Epidemiology and demographics of upper gastrointestinal bleeding: prevalence, incidence, and mortality

Despite major advances in diagnosis, prevention, and treatment, nonvariceal upper gastrointestinal bleeding still is a serious problem in clinical practice. Current evidence indicates that most peptic ulcer bleeding-linked deaths are not a direct sequela of the bleeding ulcer itself. Instead, mortality derives from multiorgan failure, cardiopulmonary conditions, or terminal malignancy, suggesting that improving further current treatments for the bleeding ulcer may have a limited impact on mortality unless supportive therapies are developed for the global management of these patients.

Bleeding Dieulafoy lesions of the small bowel: a systematic study on the epidemiology and efficacy of enteroscopic treatment

BACKGROUND

Dieulafoy lesions consist of aberrant submucosal arteries, which can cause severe GI bleeding. The predominant location of Dieulafoy lesions is the upper GI tract.

OBJECTIVE

To our best knowledge, this is the first systematic study on the frequency of bleeding from Dieulafoy lesions in the small bowel and the efficacy of enteroscopic therapy regarding primary hemostasis and long-term follow-up.

DESIGN

Multicenter, retrospective, observational study.

SETTING

Nine Austrian centers doing double-balloon enteroscopy or single-balloon enteroscopy.

PATIENTS

This study involved 284 consecutive patients who were referred for double-balloon enteroscopy or single-balloon enteroscopy because of suspicion of mid-GI bleeding.

INTERVENTION

A total of 317 double-balloon enteroscopy and 78 single-balloon enteroscopy procedures were performed in 284 patients with suspected mid-GI bleeding.

MAIN OUTCOME MEASUREMENTS

Demographic, clinical, procedural, and outcome data were collected.

RESULTS

A Dieulafoy lesion in the small bowel was identified as the source of mid-GI bleeding in 3.5% of patients, with a mean of 1.5 enteroscopy sessions required per diagnosis. In 9 cases the Dieulafoy lesion was found by enteroscopy from an oral approach, and in 1 patient the lesion was found by an anal approach. In all patients primary endoscopic hemostasis was successful. Eight of 10 patients were free from rebleeding episodes (median follow-up 14.5 months, interquartile range 10.0-17.5 months). In 2 of 10 patients, rebleeding occurred, and a surgical intervention was necessary.

LIMITATIONS

Retrospective study.

CONCLUSION

Bleeding from Dieulafoy lesions of the small bowel seems to occur more frequently than previously estimated. Most of these lesions are located in the proximal jejunum and can be managed successfully by enteroscopy. After successful endoscopic hemostasis, rebleeding episodes occur in only 20% of patients.

[Retroperitoneal hematoma after treatment of Dieulafoy's lesion of the duodenum]

Dieulafoy's lesion is an uncommon cause of brisk arterial bleeding from the gastrointestinal tract that can have severe consequences such as rebleeding and hypotension if left untreated. The authors report the case of an elderly woman with several comorbidities who presented with duodenal bleeding caused by a Dieulafoy lesion. The lesion was treated endoscopically and was subsequently complicated by the formation of a retroperitoneal hematoma. Given the surgical risk, the authors opted to retreat endoscopically, which proved to be a reasonable approach in this particular patient.

Laparoscopic treatment for small intestinal bleeding: a report of 77 cases

BACKGROUND

Morbidity of small intestinal disease is rare and the associated lesion is hard to be detected due to lack of specific manifestations and effective diagnostic approaches. Hematochezia and melena are the most common symptoms in small intestinal diseases. Hence, small intestinal disease is an important differential diagnosis when hematochezia or melena occurs, especially when gastric and colonic diseases are excluded. As the small intestinal lesion is hard to be located preoperatively, laparotomy used to be performed without a preoperative location. This might lead to related postoperative complications. With the development of laparoscopic technique, laparoscopic operations are more frequently applied to surgical disease, despite their benign or malignant nature. Generally, almost all kinds of small intestinal disease can be treated with laparoscopic surgery.

METHODS

Clinical data of 77 patients with small intestinal bleeding undergoing laparoscopic or laparoscopy-assisted operations from April 2003 to December 2008 were included, and their clinical information were analyzed retrospectively.

RESULTS

No intraoperative complication or conversion was observed in all cases. The mean operative time, mean estimated blood loss, and mean size of incision were 78.3 +/- 30.5 minutes, 17.5 +/- 9.8 mL, and 3.3 +/- 1.9 cm, respectively. Postoperative complications occurred in 4 patients, including 2 cases of adhesive ileus, 1 case of gastric retention, and 1 case of anastomotic bleeding. All of them were cured by nonoperative management. The mean flatus time was 2 days after operation and the mean postoperative hospital stay was 7 days. There was 1 case of gastrointestinal stromal tumor with local recurrence and hepatic metastasis. Four patients died from metastasis of malignant tumors during the follow-up from 2 to 70 months after operations. No trocar site or wound recurrences were noted.

CONCLUSIONS

Laparoscopic treatment in small intestinal bleeding is feasible, safe, and minimally invasive. It may be widely used in the future for its good therapeutic outcomes and improved diagnostic chance in small intestinal bleeding diseases.

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.

An uncommon cause of life-threatening gastrointestinal bleeding: 2 synchronous Dieulafoy lesions

Dieulafoy lesions are a rather uncommon cause of gastrointestinal bleeding that can be torrential and life-threatening. Extragastric location and pediatric cases are very rare. We report the first case of synchronous Dieulafoy lesions in the stomach and jejunum. This case is discussed in the light of the reported literature on this condition.

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.

[Dieulafoy's lesion: rare cause of massive upper gastrointestinal bleeding]

Dieulafoy's lesion is an unusual and potentially life-threatening cause of massive, recurrent gastrointestinal bleeding. Its reported incidence as a source of upper gastrointestinal bleeding ranges from 0.3-6.7%. Dieulafoy's lesion is most commonly located in the proximal stomach (75% of cases). Lesion typically occur within 6 to 10 cm of the esophagogastric junction, generally along the lesser curvature of the stomach. Similar lesions have been identified in the esophagus, duodenal bulb, jejunum, ileum, colorectum, anal canal, even in bronchus. Detection and identification of the Dieulafoy's lesion as the source of bleeding can often be difficult, especially because most present with massive bleeding. Because of intermittent nature of bleeding, initial endoscopy is diagnostic in 60% of the cases, so repeated endoscopies are often necessary. If the lesion can be endoscopically documented, attempts should be made to achieve hemostasis using one or a combination of several endoscopic modalities. Success has been reported with multipolar electrocoagulation, heater probe, noncontact laser photocoagulation, injection sclerotherapy, endoscopic hemoclipping and band ligation. Surgery is reserved for lesions that cannot be controlled by endoscopic techniques. When localized, a wide wedge resection of entire area traversed by the large submucosal artery is recomended because rebleeding has been described after simple coagulation and ligation.

Clinical presentation and endoscopic management of Dieulafoy’s lesions in an urban community hospital

AIM: To identify rates of occurrence, common clinical and endoscopic features, and to review the outcome of endoscopic management of Dieulafoy’s lesions in the upper gastrointestinal (GI) tract in an urban community hospital setting.

METHODS: Endoscopic data from esophagogastroduodenoscopies (EGDs), done at Wyckoff Heights Medical Center, Brooklyn, NY between 2000 and 2006 were reviewed to identify patients with Dieulafoy’s lesions. Demographic data, medical history, examination findings, lab data, endoscopic findings and details of therapy for patients treated for Dieulafoy’s lesions were reviewed retrospectively.

RESULTS: Dieulafoy’s lesions were documented to be the cause of bleeding in approximately 1% of patients presenting with upper gastrointestinal bleeding, while they were detected in only 2 patients when the indications for EGDs were different from active GI bleeding. When we analyzed EGDs performed in patients above age 65 years presenting with gastrointestinal bleeding, prevalence of Dieulafoy’s lesions approached 10 percent. The most common location of the lesion was the body of stomach (7), followed by the cardia (4) and the esophagus (2). One patient had this lesion in the fundus and one patient in the duodenal apex. All patients were initially treated endoscopically with epinephrine injection, in eight cases heater probe was applied following epinephrine and endoscopic clips were applied in two cases. All but one of the patients did well in near and intermediate term follow-up (average follow-up period of 18 mo). One patient died of multi-organ failure during the same hospital stay. Average length hospital stay was 7 d.

CONCLUSION: Community hospital gastroenterologists and endoscopists should be aware that Dieulafoy's lesions are an uncommon cause of upper GI bleeding among elderly patients. Early accurate diagnosis through emergent endoscopy and endoscopic therapy, especially in patients with multiple co-morbid conditions, can be very effective and life saving.

[Total gastrectomy in the surgical treatment of acute massive hemorrhage caused by Dieulafoy lesion of the gastric fundus]

GI bleeding caused by Dieulafoy lesion in the gastric fundus: a case report Dieulafoy lesion is a rare cause of massive gastrointestinal (GI) hemorrhage that can be fatal. It arises from an abnormally large eroded submucosal artery and in more than 75% of cases the lesion is mostly found within 6 cm of the cardia. The severity of bleeding and the site of the lesion render the diagnosis sometimes difficult, more than one endoscopic exam is often required. Surgery was regarded as the treatment of choice in the past, but recently endoscopic management has become the standard approach. We report a case of an 42-year-old man presented with upper GI hemorrhage. Repeated upper GI endoscopies revealed a missed diagnosis of subcardial gastric ulcer and Mallory-Weis lesion. Following conservative treatment, the frequency and amount of haemorrhage decreased and totally stop. 48 hours after admission patient developed sudden massive upper GI bleeding and underwent emergency total gastrectomy. The diagnosis of Dieulafoy lesion was made histologically. The patient recovered uneventfully and discharged on the postoperative day 11th. Therefore, Dieulafoy disease represent a diagnostic and therapeutic challenge. Advances in endoscopic technique have greatly assisted in earlier diagnosis and added options to the treatment regimen for this lesion. The relationship of this anomaly to possible exsanguination makes it essential that both endosopical and surgical approach play an important role in the management of this pathology.

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.

Diagnosis and treatment of small intestinal bleeding: Retrospective analysis of 76 cases

AIM: To investigate the causes of small intestinal bleeding as well as its diagnosis and therapeutic approaches.

METHODS: A retrospective analysis was conducted according to the clinical records of 76 patients with small intestinal bleeding admitted to our hospital in the past 5 years.

RESULTS: In these patients, tumor was the most frequent cause of small intestinal bleeding (37/76), followed by Meckel’s diverticulum (21/76), angiopathy (15/76) and ectopic pancreas (3/76). Of the 76 patients, 21 were diagnosed by digital subtraction angiography, 13 by barium and air double contrast X-ray examination of the small intestine, 11 by ^99mTc-sestamibi scintigraphy of the abdominal cavity, 6 by enteroscopy of the small intestine, 21 by laparoscopic laparotomy, and 4 by exploratory laparotomy. Although all the patients received surgical treatment, most of them (68/76) received part enterectomy covering the diseased segment and enteroanastomosis. The follow-up time ranged from 1 year to 5 years. No case had recurrent alimentary tract bleeding or other complications.

CONCLUSION: Tumor is the major cause of small intestinal bleeding followed by Meckel’s diverticulum and angiopathy. The main approaches to definite diagnosis of small intestinal bleeding include digital subtraction angiography, ^99mTc-sestamibi scintigraphy of the abdominal cavity, barium and air double contrast X-ray examination of the small intestine, laparoscopic laparotomy or exploratory laparotomy. Part enterectomy covering the diseased segment and enteroanastomosis are the most effective treatment modalities for small intestinal bleeding.

Application of laparoscopy in diagnosis and treatment of massive small intestinal bleeding: Report of 22 cases

AIM: To investigate the diagnostic and therapeutic value of laparoscopy in patients with massive small intestinal bleeding.

METHODS: Twenty-two patients with massive small intestinal bleeding and hemodynamic alteration underwent laparoscopic laparotomy in our unit from December 2002 to April 2005. Post pathologic sites were found, laparoscopy- or laparoscopy-assisted part small intestinal resection including pathologic intestinal site and enteroanastomosis was performed in all these patients.

RESULTS: The bleeding sites were successfully detected by laparoscopy in all these 22 patients. Massive small intestinal bleeding was caused by jejunum benign stromal tumor in 8 cases, by jejunum potential malignant stromal tumor in 5 cases, by jejunum malignant stromal tumor in 1 case, by Mechel’s diverticulum in 5 cases, by small intestinal vascular deformity in 2 cases, and by ectopic pancreas in 1 case. A total of 16 patients underwent laparoscopy-assisted enterectomy and enteroanastomosis of small intestine covering the diseased segment and 6 patients received enterectomy of the diseased segment under laparoscope. No surgical complications occurred and the outcome was satisfactory.

CONCLUSION: Laparoscopy in diagnosis and treatment of massive small intestinal bleeding is noninvasive with less pain, short recovery time and definite therapeutic efficacy.

Actively bleeding Dieulafoy’s lesion of the small bowel identified by capsule endoscopy and treated by push enteroscopy

Dieulafoy’s lesion is an unusual cause of recurrent GI bleeding. This report describes a case of actively bleeding Dieulafoy’s lesion of the small bowel in which the diagnosis was made by capsule endoscopy, followed by treatment with the use of push enteroscopy. The case illustrates that capsule endoscopy and enteroscopy are highly complementary in patients with small bowel diseases.

Dieulafoy lesion: endoscopic and surgical management

Dieulafoy lesion is characterized by exteriorization of a large pulsatile arterial vessel through a minimal mucosal tear surrounded by normal mucosa, causing massive and recurrent upper digestive bleeding in previously healthy patients. More frequently presented than diagnosed, with the increase of its knowledge among endoscopists, a large number of cases are expected in the literature. Data from patients with upper gastrointestinal bleeding submitted to endoscopy at the Federal University of São Paulo, Gastrointestinal Endoscopy Unit from 1991 through 2002 were reviewed for Dieulafoy lesion. We found 15 patients with typical Dieulafoy gastric lesion. Their ages ranged from 18 to 78 years (mean age 49.9); 5 patients were female and 10 were male. Bleeding presented as hematemesis and melena in 7 cases (46.6%), hematemesis alone in 4 cases (26.6%), and melena alone in the other 4 cases (26.6%). Initial hemostatic approaches employed were: alcoholization (2 cases), epinephrine associated with alcohol injection (5 cases), sclerosis in 7 cases and surgery in 1 case. Dieulafoy lesion is a distinct nosologic entity that must be suspected in patients with massive digestive bleeding. Endoscopy became the procedure of choice for diagnosis and treatment of this disease.

Nonvariceal upper gastrointestinal bleeding: epidemiology and diagnosis

Nonvariceal upper gastrointestinal bleeding remains an important cause of patient morbidity, mortality, and use of considerable health care resources. An early and accurate diagnosis is critical for guiding appropriate management and facilitating patient care. This article reviews the most recent epidemiologic data on acute nonvariceal upper gastrointestinal bleeding and outlines important aspects of making the diagnosis.