Endoscopic band ligation of an actively bleeding Dieulafoy lesion

Endoluminal Closure of Colon Perforation with Endoscopic Band Ligation: Technical Feasibility and Safety in an In Vivo Canine Model

BACKGROUND/AIMS

Endoscopic band ligation (EBL) is an accepted method in the management of variceal bleeding; however, there is little evidence on the safety and feasibility of EBL for the closure of bowel perforation. In this study, we aimed to evaluate the technical feasibility and efficacy of EBL in iatrogenic colon perforation by using a canine model.

METHODS

We established an iatrogenic colon perforation model by using seven beagle dogs. Longitudinal 1.5- to 1.7-cm colon perforations were created with a needle knife and an insulated-tip knife, and the perforation was subsequently closed with EBL. During a 2-week follow-up period, the animals were carefully monitored and then euthanized for pathologic examination.

RESULTS

The EBL of iatrogenic colon perforations was successful in all dogs. The mean procedure time for EBL closure with one to three bands was 191.7 seconds, and there were no immediate complications. One animal was euthanized after 3 days because of peritonitis. There were no clinical and laboratory features of sepsis or peritonitis in the remaining six animals. On necropsy, we did not find any fecal peritonitis, pericolonic abscess formation, or transmural dehiscence at the perforation site. Histopathology demonstrated inflamed granulation tissue and scar lesions replaced by fibrosis.

CONCLUSIONS

EBL might be a feasible and safe method for the management of iatrogenic colon perforations in an in vivo model.

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.

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.

Is endoscopic band ligation superior to injection therapy for Dieulafoy lesion?

BACKGROUND

Dieulafoy lesion is a rare but serious cause of gastrointestinal system bleeding. An aberrant submucosal artery, which was described in 1884, causes the bleeding. The lesion can be located anywhere in the gastrointestinal tract but is most commonly found in the proximal stomach up to 6 cm from the gastroesophageal junction. Increased experience in endoscopy has led to an increased frequency of its proper diagnosis. Various methods are used to achieve successful hemostasis by endoscopy in Dieulafoy lesion; however, comparative studies about the success rates of these methods are still needed. In this study, we compared two of these endoscopic hemostatic methods: band ligation, and injection therapy in Dieulafoy lesions.

METHODS

In this prospective study, 18 patients admitted to the Emergency Surgical Unit between January 2002 and December 2005 with upper gastrointestinal bleeding diagnosed as Dieulafoy lesion were included. Diagnose of Dieulafoy lesion was made at initial or second-look endoscopy. Patients were randomized in two groups according to therapy method: injection therapy and band ligation groups. Therapy was applied immediately after recognizing the lesion at the same endoscopic procedure. Two groups were compared regarding demographical data, presence of comorbid diseases, history of medication and previous gastrointestinal system bleeding, hemodynamic status, laboratory values, need for transfusion, endoscopic findings, success rate of the treatment method, mean hospital stay, complications, and recurrence of bleeding.

RESULTS

Of 588 patients admitted with upper gastrointestinal hemorrhage, Dieulafoy lesion was recognized in 18 cases (3.1%) at initial or second-look endoscopy. All patients were men with a mean age of 62.8 (range, 30-80) years. Band ligation was applied to ten patients and the remaining eight were treated by injection therapy. During the follow-up period, rebleeding occurred in six of the patients (75%) with injection therapy, whereas no rebleeding occurred for the patients in the band ligation group. The rebleeding rate and mean hospital stay was significantly higher for the injection therapy group.

CONCLUSIONS

Our study suggests that of the endoscopic treatment methods, band ligation is superior to injection therapy for the treatment Dieulafoy lesions.

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.

Endoscopic band ligation therapy for upper gastrointestinal bleeding related to Mallory-Weiss syndrome

BACKGROUND

No consensus exists as to the best endoscopic treatment for Mallory-Weiss syndrome. Endoscopic band ligation is a readily available and easily learned technique. This prospective study evaluated the efficacy and safety of endoscopic band ligation therapy for Mallory-Weiss syndrome.

METHODS

From August 1998 to June 2005, a clinical trial assessed 37 patients with a diagnosis of Mallory-Weiss syndrome who had active bleeding, exposed vessels, or both. Their lesions were treated using endoscopic band ligation.

RESULTS

Endoscopic band ligation was successful in 36 of 37 cases, with a follow-up period ranging from 1 to 24 months. The remaining patient had severe liver failure and disseminated intravascular coagulation. The patient bled again at 12 h and subsequently died. Except for this case, no recurrent bleeding, perforation, or other complications occurred.

CONCLUSIONS

The study results suggest that endoscopic band ligation is an effective, safe, and easily learned procedure for treating upper gastrointestinal bleeding related to Mallory-Weiss syndrome.

Usefulness of endoscopic band ligation for bleeding small bowel vascular lesions

BACKGROUND

The optimal therapy for bleeding small bowel vascular lesions is controversial. This study investigated the efficacy and safety of endoscopic band ligation in this clinical condition.

METHODS

Fourteen patients bleeding from angiodysplasia and 4 bleeding from Dieulafoy's lesions located in the small bowel were included in this pilot study. Endoscopic band ligation was performed by using less than 200 mBar negative pressure in suctioning the target lesion into the ligation cap just before band release. Mean follow-up was 18 months (range 6-31 months).

OBSERVATIONS

Endoscopic band ligation achieved hemostasis in a single session in all patients. No adverse events occurred except for mild abdominal pain in two patients. Mortality was null, and no patient required further blood transfusion during the 40 days after endoscopic band ligation. No patient with Dieulafoy's lesion had further bleeding, whereas bleeding recurred in 6 of 14 (43%) patients with angiodysplasia during long-term follow-up.

CONCLUSIONS

Endoscopic band ligation is safe and effective for treatment of acutely bleeding small bowel vascular lesions. Although endoscopic band ligation is definitive therapy for Dieulafoy's lesion, long-term efficacy in the treatment of GI bleeding from angiodysplasia is limited.

Outcomes of endoscopic treatment of gastroduodenal Dieulafoy's lesion with rubber band ligation and thermal/injection therapy

BACKGROUND

Dieulafoy's lesion is a rare but important cause of upper gastrointestinal bleeding. Current endoscopic methods used to treat Dieulafoy's lesion include injection, with or without thermal methods, and mechanical methods. The latter include variceal ligation and hemoclips. There are no studies comparing the outcomes of rubber band ligation and injection with or without thermal therapy.

AIM

To report the outcomes of Dieulafoy's lesion treated endoscopically with rubber band ligation and injection with or without thermal therapy at a single institution.

METHODS

Patients with the diagnosis of Dieulafoy's lesion treated endoscopically at the Carl T. Hayden VA Medical Center in Phoenix, between August 1994 and August 2002 were analyzed. Demographic data, mode of presentation, risk factors for gastrointestinal bleeding, hemodynamic parameters, blood transfusion requirements, endoscopic findings, details of endoscopic therapy, length of stay in ICU/hospital, complications, recurrence of bleeding, and mortality rates were collected and compared between those receiving endoscopic band ligation (EBL group) and those receiving injection with or without thermal therapy (non-EBL group).

RESULTS

Twenty-three patients with Dieulafoy's lesion (14 in the EBL group and nine in the non-EBL group) were studied. All patients were men. The mean age, hemoglobin levels on admission, and the transfusion requirements before therapy were similar in both groups. Fourteen patients (eight in the EBL- and six in the non-EBL groups) presented with hematemesis and the remaining with melena. The majority of Dieulafoy's lesions (91.3%) were located in the stomach and two in the duodenum. Active bleeding at the time of endoscopy was seen in 61% of cases, and immediate hemostasis was achieved with either method in 100% of patients. Early rebleeding (within 72 hours of endoscopic therapy) occurred in only one patient treated with epinephrine plus heater probe therapy. The length of stay in ICU was longer in the non-EBL group (6.7 days) compared with the EBL group (1.8 days) (P = 0.2). There were six deaths (three in the non-EBL group and three in the EBL group) within 30 days of the index hospitalization. The causes of death included infection/sepsis (n = 3), complications of acute myocardial infarction (n = 2), and end-stage liver disease (n = 1).

CONCLUSIONS

Endoscopic rubber band ligation is as effective as injection with or without thermal therapy in the treatment of Dieulafoy's lesion.

Endoscopic band ligation for control of nonvariceal upper GI hemorrhage: comparison with bipolar electrocoagulation

BACKGROUND

Despite advances in endoscopic treatment methods for upper GI hemorrhage, hemostasis is often difficult to achieve. This study evaluated the usefulness of endoscopic band ligation for upper GI hemorrhage exclusive of hemorrhage from chronic gastroduodenal ulcer and varices.

METHODS

This prospective study included 27 patients who underwent endoscopic band ligation and 31 patients in whom bipolar electrocoagulation was performed for upper GI hemorrhage. In both groups, the causes of hemorrhage included Dieulafoy's ulcer, Mallory-Weiss tear, gastric ulcer after polypectomy, and gastric angiodysplasia. Patients with esophageal varices and those with chronic gastroduodenal ulcer were excluded.

RESULTS

Hemostasis was achieved in all 27 patients in the endoscopic band ligation group and in 26 of 31 patients (83.9%) in the bipolar electrocoagulation group. The median procedure time required for achieving hemostasis was 17.0 minutes (interquartile range: 11.5-23.5) in the endoscopic band ligation group versus 27.0 minutes (interquartile range: 20.5-40.0) in the electrocoagulation group. No major complications occurred in either group.

CONCLUSION

Endoscopic band ligation is efficient, simple, and safe. Therefore, this technique should be considered as a treatment option for nonvariceal, nonchronic gastroduodenal ulcer upper GI hemorrhage.

Dieulafoy's lesion of the small bowel causing massive gastrointestinal bleeding: two case reports and literature review

Dieulafoy's lesions are an often unrecognized cause of obscure, massive GI hemorrhage. Their diagnosis may elude conventional investigations, including upper and lower endoscopy, arteriography, and even laparotomy. In this paper, we report two cases of small-bowel Dieulafoy lesions. The first, a jejunal lesion, occurred in a young patient and was discovered at laparotomy. The second was an ileal Dieulafoy's malformation in an older patient. An intraoperative endoscopy with surgical guidance may be needed for definitive localization of this lesion.

Bleeding Dieulafoy's lesions and the choice of endoscopic method: comparing the hemostatic efficacy of mechanical and injection methods

BACKGROUND

Dieulafoy's lesion has unique endoscopic and histopathologic characteristics. This is a clinical trial of endoscopic therapy in 24 patients with Dieulafoy's lesions.

METHODS

Patients were divided into 2 groups according to initial endoscopic treatment method. Data were analyzed with respect to clinical and endoscopic characteristics as well as outcomes. The 24 patients were evenly divided into mechanical (9 hemoclipping, 3 band ligation) and injection groups (12).

RESULTS

The average number of therapeutic endoscopic sessions needed to achieve permanent hemostasis for the mechanical and injection groups were 1.17 and 1.67, respectively. Initial hemostasis was achieved in 91.7% of patients undergoing mechanical therapy and 75% of those undergoing injection therapy, with none in the former group needing subsequent surgery in comparison to 17% of the latter group. The rate of recurrent bleeding in the mechanical therapy group was significantly lower in comparison to the injection therapy group (8.3% versus 33.3%, p < 0. 05).

CONCLUSIONS

Higher efficacy in terms of initial hemostasis and less recurrent bleeding was achieved by mechanical hemostatic therapy with hemoclip and band ligation compared with injection therapy. Endoscopic mechanical therapy is recommended as effective for bleeding Dieulafoy's lesions.

Dieulafoy's lesion of the anal canal: a new clinical entity. Report of two cases

Dieulafoy's lesion is an unusual source of massive lower gastrointestinal hemorrhage. It is characterized by severe bleeding from a minute submucosal arteriole that bleeds through a punctate erosion in an otherwise normal mucosa. Although Dieulafoy's lesions were initially described only in the stomach and upper small intestine, they are being identified with increasing frequency in the colon and rectum. To our knowledge, however, Dieulafoy's lesion of the anal canal has not been described previously. We present two patients with Dieulafoy's lesion of the anal canal who presented with sudden onset of massive hemorrhage. The clinicopathologic features of this unusual clinical entity are discussed and suggestions are made for diagnosis and management.

Management and long-term prognosis of Dieulafoy lesion

BACKGROUND

The Dieulafoy lesion is an important cause of gastrointestinal (GI) hemorrhage. Optimal treatment and long-term outcome are unknown. This study aimed to characterize the presentation of the Dieulafoy lesion and to summarize the results and report the long-term outcome of endoscopic therapy.

METHODS

Data regarding diagnosis, treatment and outcomes were derived from our GI Bleed Team database, patient records and follow-up correspondence.

RESULTS

Ninety Dieulafoy lesions were identified in 89 patients after a mean of 1.9 endoscopies. Their mean age was 72 years. Thirty-four percent of lesions were extragastric. Median transfusion requirement was 5 units. Two patients exsanguinated and 3 required surgery; all others were initially successfully treated endoscopically (with or without epinephrine injection): heat probe (71 patients), band ligation (3), hemoclip (1), laser (2), bipolar probe (4), sclerotherapy (2) and epinephrine alone (2). Gastric perforation occurred in 1 patient following sclerotherapy. Thirty-day mortality was 13%, 4 related to hemorrhage and 5 related to comorbidity. During median follow-up of 17 months, 34 patients (42%) died. One patient had recurrent bleeding 6 years after operation.

CONCLUSIONS

Dieulafoy lesion is relatively common and often extragastric. Endoscopic therapy is safe and effective. Long-term recurrence was not evident following endoscopic ablation. Follow-up after ablative therapy appears unnecessary.

Endoscopic band ligation of Dieulafoy's lesion: report of two cases and review of the literature

Two cases of endoscopic band ligation as lone therapy for Dieulafoy's lesions are presented. Neither patient has experienced further gastrointestinal bleeding; one patient has been followed for 27 months. Endoscopic band ligation is an alternative and attractive treatment modality for Dieulafoy's lesions.

Endoscopic band ligation for non-variceal non-ulcer gastrointestinal hemorrhage

BACKGROUND

There is no consensus as to the best treatment for non-variceal, non-ulcer gastrointestinal hemorrhage. Endoscopic band ligation is an inexpensive, readily available, and easily learned technique in contrast to conventional thermal methods of endoscopic hemostasis. We present the preliminary results of an open trial using endoscopic band ligation for non-variceal, non-ulcer bleeding in the gastrointestinal tract.

METHODS

Eighteen patients were treated by band ligation between June 1996 and November 1997. The lesions treated were: arteriovenous malformations in 10, Dieulafoy's lesions in 4, Mallory-Weiss tear in 2, and post-colonic polypectomy bleeding in 2.

RESULTS

Endoscopic band ligation was successful in 17 of 18 cases, with a follow-up period ranging from 2 to 18 months. The remaining case, a duodenal Dieulafoy's lesion, bled again at 24 hours but was successfully treated by adrenalin injection.

CONCLUSIONS

Endoscopic band ligation is effective for non-variceal, non-ulcer bleeding. It has the advantage of ease of use and is relatively inexpensive.

Dieulafoy's disease treated by endoscopic haemostatic clipping

Dieulafoy's disease is an uncommon cause of upper gastrointestinal haemorrhage. We report three patients with Dieulafoy's disease treated with the endoscopic haemostatic clip application. There was no recurrent bleeding from the upper gastrointestinal tract after application of the clips in all three patients. Two patients survived while the third succumbed to renal failure after hypovolaemic shock. We conclude that endoscopic haemostatic clip may have a role in the treatment of Dieulafoy's disease.

Dieulafoy's disease: endosonographic detection and endosonography-guided treatment

BACKGROUND

To investigate whether endosonography can help in the detection and treatment of Dieulafoy's disease, we examined eight patients with suspicion of Dieulafoy's disease.

METHODS

Between December 1992 and April 1995, eight patients were referred because of suspicion of Dieulafoy's disease. Seven presented with upper gastrointestinal bleeding and one with a tiny ulcer. In all eight patients the stomach was examined with an Olympus GF-UM20 echoendoscope. The stomach was filled with 200 to 400 ml of water after which the body, fundus, and cardia were carefully visualized.

RESULTS

In all eight patients a clearly visible, relatively large caliber (2 to 3 mm) vessel was seen to penetrate the muscularis propria and could be followed running through the submucosa for 2 to 4 cm. Subsequently four patients received sclerotherapy, three under endosonographic guidance. Follow-up of all patients (median 10 months), showed recurrent bleeding in two patients, 3 and 5 months after sclerotherapy. One was then diagnosed with a duodenal ulcer and one with recurrent bleeding from the Dieulafoy's lesion.

CONCLUSIONS

Endosonography is useful in the detection of Dieulafoy's disease in patients with unexplained upper gastrointestinal bleeding. Sclerotherapy can be performed during the same procedure, with endosonography-guided injection of the sclerosing agent near the abnormal vessel.