Two cases of Dieulafoy's lesion in unusual sites: A rare case reports of gastrointestinal bleeding

INTRODUCTION

Dieulafoy's lesion (DL) is a vascular malformation that can lead to massive gastrointestinal bleeding. It's usually found in the stomach. However, DL's occurrence in atypical sites such as the small bowel and colon is exceptionally rare, posing significant management challenges.

CASE PRESENTATION

In this report, we present two cases of DL occurring in uncommon sites, each managed with distinct approaches. Case 1 is a 50-year-old man admitted to the emergency department due to massive GI bleeding and hemodynamic instability. The diagnosis of DL was established through computed tomography angiography and confirmed by histopathological examination after emergency surgery. Case 2 involves a 68-year-old woman presented with melena due to a colonic DL. This case was successfully managed through an endoscopic hemostasis approach.

DISCUSSION

Dieulafoy's lesions (DL) were first identified as a large submucosal artery lacking typical gastric ulcer characteristics in three of Paul Georges Dieulafoy's patients. This lesion is responsible for approximately 1-2 % of all cases of gastrointestinal bleeding. Endoscopy is the preferred method for diagnosing and managing DL lesions, especially in cases of active bleeding that is accessible. However, if endoscopic treatment or angiographic embolization fails, a surgical approach may be needed.

CONCLUSION

DL presents a diagnostic challenge due to its rarity and is not usually included in the differential diagnosis of gastrointestinal bleeding, particularly when occurring in unusual sites. Endoscopy is the preferred method to identify DL and a possible therapeutic approach in active bleeding. However, if endoscopy hemostasis fails, angiographic embolization or surgical intervention may be required.

Dieulafoy's lesion: Is there still a place for surgery? About 2 cases

INTRODUCTION

Dieulafoy's lesion, a rare but life-threatening condition accounting for a small percentage of acute gastrointestinal bleeding cases, has historically posed diagnostic and therapeutic challenges.

CASE PRESENTATION

In this article, we present two cases that required surgical intervention due to unsuccessful attempts with endoscopy. Case 1 involved a 40-year-old patient with a history of treated duodenal ulcers, while Case 2 featured a 74-year-old woman with no notable medical history. Both patients exhibited severe bleeding, necessitating urgent surgical procedures. The surgical approach involved wide gastrotomy, careful inspection, and successful suturing of the bleeding vessel.

DISCUSSION

Dieulafoy lesions, discovered by French surgeon Georges Dieulafoy in 1885, constitute 1-2 % of acute gastrointestinal bleeding cases. These anomalies involve enlarged submucosal arteries, predominantly in the stomach, but occurrences in other sites are documented. Endoscopic methods, surpassing surgical intervention, are preferred for treatment, boasting success rates over 90 %. Surgical measures become a last resort for uncontrolled bleeding, with laparoscopic surgery emerging as a minimally invasive alternative, facilitated by various intra-operative localization techniques. Laparoscopic wedge resection, in particular, exhibits lower re-bleeding rates than traditional oversewing methods, although feasibility depends on lesion location.

CONCLUSION

While endoscopic methods are preferred, surgery remains a vital option when bleeding persists or endoscopic intervention fails. This report highlights the significance of surgical management in selected cases of Dieulafoy's lesion.

Upper gastrointestinal bleeding due to Dieulafoy's lesion of the stomach: a rare case report

Dieulafoy's lesion is a life-threatening and rare vascular malformation of the submucosal vessel that protrudes to the mucosa of the gastrointestinal tract. The vessel is abnormally dilated, and if it ruptures, it can cause severe acute gastrointestinal bleeding. We report an upper GI bleeding case due to Dieulafoy's lesion in the gastric fundus of the stomach in a 76-year-old female. The patient presented with hematemesis and melena associated with anemia. An esophagogastroduodenoscopy (OGD) was performed which showed profuse pulsatile bleeding at the gastric fundus. Following that, gastrotomy confirmed the diagnosis of Dieulafoy's lesion. Endoscopy is the main diagnostic and therapeutic tool for Dieulafoy's lesion. Endoscopic treatment includes injective, ablative and mechanical therapies. The majority of cases are treated endoscopically, while in some cases, surgical intervention is deemed to be necessary as it is currently the only definitive treatment of Dieulafoy's lesion.

Clinical outcomes of Dieulafoy's lesion compared with peptic ulcer in upper gastrointestinal bleeding

BACKGROUND AND AIM

Although Dieulafoy's lesion (DL) is an important cause of nonvariceal upper gastrointestinal (GI) bleeding, few studies have investigated the clinico-epidemiological outcomes due to its rarity. Here, we investigated clinical features of upper GI bleeding caused by peptic ulcer (PU) or DL and compared endoscopic treatment outcomes.

METHODS

Patients with upper GI bleeding resulting from PU or DL who visited emergency room between January 2013 and December 2017 were eligible. Clinical features and treatment outcomes were retrospectively investigated.

RESULTS

Overall, 728 patients with upper GI bleeding due to PU (n = 669) and DL (n = 59) were enrolled. The median age was 64 years (interquartile range [IQR], 56-75 years), and 74.3% were male. Endoscopic intervention was performed in 53.7% (n = 359) and 98.3% (n = 58) of the PU and DL groups, respectively (P < 0.0001). Patients were matched by sex, age, body mass index, comorbidity, and past medical history, and 190 PU and 52 DL were finally selected. The rebleeding rates within 7 (7.37% vs 17.31%, P = 0.037) and 30 (7.37% vs 26.92%, P < 0.001) days after initial endoscopy were significantly lower in the PU than in the DL group after propensity score matching. During the median follow-up period of 52 months (IQR, 34-70 months), there was no difference in overall survival rate (67.9% vs 82.7%, P = 0.518).

CONCLUSIONS

Although DL is a rare cause of upper GI bleeding, it requires endoscopic hemostasis more frequently and has a higher rate of rebleeding than PU even after therapeutic endoscopy. Endoscopists should pay attention and perform active endoscopic hemostasis for DL bleeding.

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.

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.

Rare case of upper gastrointestinal bleeding: Dieulafoy' s lesion of duodenum. A case report

Dieulafoy's lesion is an uncommon but important cause of recurrent upper gastrointestinal bleeding. Extragastric location of Dieulafoy's lesion is rare. We report a case of haemorrhagic shock due to delafoy ulcer of the duodenum. After the failure of endoscopic haemostatic treatment, and due to the hemodynamic instability, the patient was not a candidate for transarterial embolization, the emergency surgery was needed to stop the bleeding. Using minimally invasive technique, we were able to avoid radical surgery, in critical patient would have high mortality rate. Aggressive endoscopic examinations combined with the accurate treatment endoscopic, or after the failure of this, in cases of severe hemorrhagic shock, surgical approach should be adopted when Dieulafoy-like lesion is suspected as a possible cause of upper GI haemorrhage.

Rectal Dieulafoy's Lesion: A Rare Etiology of Lower Gastrointestinal Hemorrhage

A Dieulafoy's lesion is defined as a dilated submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. It is a rare cause of gastrointestinal bleeding that is difficult to identify and subsequently manage. Most commonly, they occur in the upper gastrointestinal tract, namely the stomach. A Dieulafoy's lesion of the rectum, however, is an exceedingly rare presentation that can lead to life-threatening gastrointestinal bleeding. Our case consists of an 84-year-old man, who presented with lower gastrointestinal bleeding secondary to a Dieulafoy's lesion of the rectum.

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.

Progress in diagnosis and treatment of colorectal Dieulafoy's disease

Dieulafoy's lesion, also named calibre persistent submucosal artery, is one of the rare and fatal causes of gastrointestinal bleeding, which can occur throughout the digestive tract. About 4% of Dieulafoy's lesions are located in the colon and rectum, especially in the rectum, cecum, and ascending colon. At present, the etiology and pathogenesis of colorectal Dieulafoy's disease are still not completely clear. The main clinical manifestation of colorectal Dieulafoy's disease is recurrent and massive hematochezia, and there may be no clinical manifestation during the intermittent period of the hemorrhage. The diagnosis and treatment of Dieulafoy's disease mainly rely on endoscopy, but due to the operating difficulties, clinical characteristics, and other factors, the treatment and diagnosis of this disease remain a challenge to clinicians. In this paper, we will discuss the pathology, etiology, pathogenesis, pathology, diagnosis, and treatment of colorectal Dieulafoy's lesion.

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.

Emergency double-balloon enteroscopy combined with real-time viewing of capsule endoscopy: a feasible combined approach in acute overt-obscure gastrointestinal bleeding?

BACKGROUND AND AIM

There are few data concerning emergency double-balloon enteroscopy (DBE) and its usefulness in the management of severe acute obscure gastrointestinal bleeding (OGIB). The aim of this retrospective study was to evaluate emergency DBE and capsule endoscopy (CE) in patients with overt OGIB, analyzing the feasibility of this combined approach.

METHODS

Emergency DBE in patients with overt OGIB was defined as performance within 24 h of symptom onset. We reported 27 patients (16 men, mean age: 64.6 ± 17.9 years) with overt severe bleeding who underwent 29 emergency DBE (22 anterograde, 7 retrograde). Of 27 patients, 16 (59.3%) underwent CE with real time (RT) viewing.

RESULTS

Patients were diagnosed with the following: Dieulafoy's lesion (DL; n = 11, 40.7%), angioectasia (n = 7, 25.9%), tumors (n = 4, 14.8%), diverticulum (n = 3, 11.1%), ulcers (n = 2, 7.4%). We diagnosed 23 lesions amenable to endoscopic hemostasis and successfully treated 21 of them (77.8%). DL detection rate was statistically higher in the emergency DBE group than in OGIB patients with DBE done 24 h after symptom onset (40.7% vs 0.9%, respectively, P < 0.001). Combined approach with RT viewing by CE correctly modified DBE management in four patients (25%).

CONCLUSIONS

Emergency DBE is feasible, safe and effective in acute OGIB and may avoid major surgery, diagnosing and successfully treating most patients. Combined approach with RT viewing by CE is especially useful to identify recurrent bleeding vascular lesions such as DL that may be easily misdiagnosed by non-emergency DBE.

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.

Diagnosis and treatment of Dieulafoy's lesion: an analysis of 13 cases

AIM: To explore the clinical features, diagnosis and treatment of Dieulafoy's lesion.

METHODS: Thirteen cases of Dieulafoy's lesion were reviewed and analyzed on the basis of clinical features, diagnosis, treatment and effect.

RESULTS: In this series, 6 cases showed hematemesis, 2 showed melena and 5 showed both symptoms. All cases underwent endoscopic examination after being hospitalized; 11 cases received a positive diagnosis by endoscopy (11/13, 85%), the success rate of first endoscopic therapy was 91% (10/11), and 4 cases were treated by laparotomic surgery (4/13, 31%). Among them, definitive surgery was performed under the guidance of endoscopic hemoclipping in 2 patients who failed to be treated by endoscopy. In another 2 cases, diagnosis was missed by endoscopy and definite diagnosis was made only following exploratory operation or on the basis of pathology after the operation. None of 10 patients showed recrudescence by follow-up study.

CONCLUSION: It is necessary to understand the clinical pattern and pathological characteristics of Dieulafoy's lesion in order to improve the diagnosis rate. Endoscopic therapy is the first-choice method for diagnosis, with good security, validity and long-term results.