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Alvi AT, Tchouambou E, Shankar M. Percutaneous Endoscopic Gastrostomy: A Possible Trigger for Dieulafoy's Lesion. HCA HEALTHCARE JOURNAL OF MEDICINE 2024; 5:45-48. [PMID: 38560388 PMCID: PMC10939086 DOI: 10.36518/2689-0216.1587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Introduction Upper gastrointestinal (GI) bleeding is a medical condition commonly seen in clinical practice due to variable etiologies and a multitude of presentations. The patients can present with hematemesis, melena, or hematochezia in case of severe bleeding. The initial evaluation should involve assessing the hemodynamic status with adequate resuscitation followed by diagnostic tests to identify the source and potentially treat it. Dieulafoy's lesion, sometimes referred to as Dieulafoy's disease, is a rare cause of upper GI bleeding with no clear risk factors, which makes it a diagnostic conundrum. Here we describe an unusual case of Dieulafoy's lesion developing following percutaneous endoscopic gastrostomy (PEG) placement. Case Presentation We describe a case of a 70-year-old female patient with a past medical history of hyperlipidemia, well-controlled hypertension, and an ischemic cerebrovascular accident, which caused neurologic dysphagia and placement of a PEG tube 3 weeks prior. She presented to the emergency department due to melena, with hypotension of 90/50 mmHg, tachycardia of 126 beats/minute, and hemoglobin of 5.6 g/dl. An endoscopy revealed a Dieulafoy's lesion on the lesser curvature of the stomach just across the PEG tube, which was managed with epinephrine and hemoclips. Conclusion This is a rare case of Dieulafoy's lesion on the lesser curvature of the stomach, potentially developing due to PEG placement.
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2
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Wallace L, Gallagher PJ. A diagnostic dilemma: a case report of concomitant duodenal Dieulafoy lesion and gastric ulcer. J Surg Case Rep 2024; 2024:rjae122. [PMID: 38463735 PMCID: PMC10924729 DOI: 10.1093/jscr/rjae122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/14/2024] [Indexed: 03/12/2024] Open
Abstract
Dieulafoy lesions (DL) are an uncommon cause of gastrointestinal bleeding which is often difficult to diagnose due to the rarity of the condition and varying clinical presentations. This case describes an unusual presentation of upper gastrointestinal bleeding in an 85-year-old female with findings on two separate gastroscopies of both a gastric ulcer and duodenal DL. The pathophysiology of DL remains poorly understood and despite shared risk factors, these two pathologies are rarely reported concurrently. The presence of a concomitant gastric ulcer further complicated the diagnosis and treatment of the duodenal DL in this case. This highlights the importance of clinician awareness of this pathology and its presentation and the need for early repeat endoscopy.
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Affiliation(s)
- Lauren Wallace
- Department of General Surgery, The Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria, 3052, Australia
- Department of Surgery, Grampians Health Wimmera Base Hospital, 83 Baillie Street, Horsham, Victoria, 3400, Australia
| | - Peter J Gallagher
- Department of Surgery, Grampians Health Wimmera Base Hospital, 83 Baillie Street, Horsham, Victoria, 3400, Australia
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Muacevic A, Adler JR, Loomis III JR, Thomas JA. Diagnosis and Treatment of a Recurrent Bleeding Dieulafoy's Lesion: A Case Report. Cureus 2022; 14:e32051. [PMID: 36600857 PMCID: PMC9802011 DOI: 10.7759/cureus.32051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
Dieulafoy's lesions are uncommon causes of upper gastrointestinal bleeding (UGIB) that pose a life-threatening risk if not diagnosed promptly and treated appropriately. These lesions are composed of enlarged submucosal blood vessels that bleed despite any gross abnormality. Early intervention with esophagogastroduodenoscopy (EGD) is necessary to avoid more invasive treatment with angiogram embolization or surgical removal. This paper aims to discuss a case regarding a patient with difficult-to-control recurrent bleeding from a Dieulafoy's lesion located in the gastric fundus of a previously healthy 60-year-old female. This case highlights the need for dual therapy and special considerations regarding antiplatelet medications and supplements when treating patients with Dieulafoy's lesions.
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Kalantari ME, Sardarzadeh N, Mirsadeghi A, Bagherzadeh AA, Zandbaf T. Jejunal Dieulafoy's Lesion as a Rare Cause of Massive Gastrointestinal Bleeding; a Case Report and Literature Review. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e61. [PMID: 36033991 PMCID: PMC9397588 DOI: 10.22037/aaem.v10i1.1623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Jejunal Dieulafoy's lesion is difficult to diagnose due to its rarity, intermittent hemorrhage, and lesion site, which is largely inaccessible to conventional endoscopes. A 39-year-old man, who had no underlying disease, presented to the emergency department (ED) with weakness, dizziness, and dry cough with a history of several rectal bleeding episodes in the last few years. Endoscopy was normal, and the colon was full of clots on colonoscopy, and no gross pathology was found. On computed tomography (CT) angiography, a hyperdensity was seen in the middle of the jejunum, possibly suggesting contrast extravasation. Due to decreased hemoglobin of the patient, and hemodynamic instability, the patient became a candidate for surgery. A palpable lesion in the Jejunum was touched that opened longitudinally, which revealed active arterial bleeding from the nipple-like lesion. This segment was resected, and an anastomosis was performed. Histopathological examination of the small intestine confirmed a Dieulafoy's lesion. It seems that, when upper endoscopy and colonoscopy fail to identify the cause of gastrointestinal bleeding, a Dieulafoy's lesion should be included in the differential diagnoses.
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Affiliation(s)
| | - Newsha Sardarzadeh
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Mirsadeghi
- Department of General Surgery, Faculty of Medicine, Mashhad Medical Sciences, Islamic Azad University, Mashhad, Iran
| | - Ali Akbar Bagherzadeh
- Innovative Medical Research Center, Faculty of Medicine, Mashhad Medical Sciences, Islamic Azad University, Mashhad, Iran
| | - Tooraj Zandbaf
- Department of General Surgery, Faculty of Medicine, Mashhad Medical Sciences, Islamic Azad University, Mashhad, Iran,Corresponding author: Tooraj Zandbaf; Faculty of Medicine, Bazarche Sarab, Imam Khomeini 14, Mashhad, Iran. ,https://orcid.org/0000-0002-4882-5058, Tel:+98-9155114523 ; +98-513-2250041 ,Fax Number: +98-513-2250048
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Perez Del Nogal G, Modi R, Salinas I, Chakrala K. Incidental massive lower gastrointestinal hemorrhage caused by a rectal Dieulafoy's lesion. BMJ Case Rep 2021; 14:e244264. [PMID: 34497057 PMCID: PMC8438715 DOI: 10.1136/bcr-2021-244264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 11/04/2022] Open
Abstract
A Dieulafoy's lesion is a rare cause of massive gastrointestinal (GI) bleeding. It represents an abnormally dilated submucosal artery that erodes the overlying epithelium in the absence of a primary ulcer. These lesions are usually located in the stomach, nevertheless, they have been found in all areas of the GI tract, including the oesophagus, duodenum and colon. Bleeding episodes are often self-limited, although bleeding can be recurrent and profuse. The case describes a 50-year-old woman who developed haemorrhagic shock secondary to a rectal Dieulafoy's lesion and discusses the diagnostic and therapeutic approaches.
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Affiliation(s)
- Genesis Perez Del Nogal
- Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Permian Basin, Odessa, Texas, USA
| | - Rangesh Modi
- Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Permian Basin, Odessa, Texas, USA
| | - Ivania Salinas
- Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Permian Basin, Odessa, Texas, USA
| | - Kalyan Chakrala
- Gastroenterology, Medical Center Hospital, Odessa, Texas, USA
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Hakimian S, Raines D, Reed G, Hanscom M, Stefaniwsky L, Petersile M, Rau P, Foley A, Cave D. Assessment of Video Capsule Endoscopy in the Management of Acute Gastrointestinal Bleeding During the COVID-19 Pandemic. JAMA Netw Open 2021; 4:e2118796. [PMID: 34328500 PMCID: PMC8325069 DOI: 10.1001/jamanetworkopen.2021.18796] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Evaluation of acute gastrointestinal (GI) bleeding using invasive endoscopic procedures comprising the standard of care (SOC)-upper endoscopy and colonoscopy-can expose the endoscopy staff to SARS-CoV-2. Video capsule endoscopy (VCE) does not generate aerosols and only requires 1 person to manage the procedure. OBJECTIVE To examine the safety of VCE for the initial evaluation of GI bleeding at the peak of the COVID-19 pandemic to identify signs of active bleeding while minimizing patient and personnel exposure, saving personal protective equipment, and avoiding invasive or unnecessary procedures. DESIGN, SETTING, AND PARTICIPANTS A multicenter (UMass Memorial Medical Center and Louisiana State University Health Sciences Center) retrospective cohort study including 146 patients with COVID-19 who received VCE as the first-line diagnostic modality was conducted from March 15 to June 15, 2020, compared with SOC in January 2020 for evaluation of GI bleeding. The association between treatment and outcomes was estimated using multivariable regression adjusting for potential confounders. Propensity score matching was used to verify the results. MAIN OUTCOMES AND MEASURES The primary end point was detection of active bleeding or stigmata of recent bleeding. Secondary end points included the number of patients requiring any invasive procedures, number of additional procedures, rates of rebleeding and rehospitalization, transfusion requirements, and mortality. RESULTS Among 146 patients, 92 (63.0%) were men; mean (SD) age was 64.93 (14.13) years in the COVID-19 group and 61.33 (13.39) years in the SOC group. Active bleeding or stigmata of recent bleeding was observed in 44 (59.5%) patients in the COVID-19 group compared with 18 (25.0%) in the SOC group (adjusted odds ratio, 5.23; 95% CI, 2.23 to 12.27). Only 36 patients (48.7%) in the COVID-19 group required any invasive procedure during the hospitalization compared with 70 (97.2%) in the SOC group (adjusted odds ratio, 0.01; 95% CI, 0.001 to 0.08). The mean (SD) number of invasive procedures was 0.59 (0.77) per patient in the COVID-19 group compared with 1.18 (0.48) per patient in the SOC group (adjusted difference, -0.54; 95% CI, -0.77 to -0.31). Both approaches appeared to be safe and there was no significant difference in transfusion requirements, rebleeding, rehospitalization, or in-hospital mortality. No mortality was attributed to GI bleeding in either group. CONCLUSIONS AND RELEVANCE In this cohort study, first-line diagnostic evaluation of acute GI bleeding using VCE appeared to be a safe and useful alternative to the traditional approach of upper endoscopy and colonoscopy. Use of VCE was associated with increased detection of active bleeding and a reduced number of invasive procedures and unnecessary exposure of personnel to SARS-CoV-2 and use of personal protective equipment.
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Affiliation(s)
- Shahrad Hakimian
- Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester
- now with Department of Medicine, Division of Digestive Diseases, University of California, Los Angeles
| | - Daniel Raines
- Section of Gastroenterology, Louisiana State University Health Sciences Center, New Orleans
| | - George Reed
- Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester
| | - Mark Hanscom
- Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester
| | - Lilia Stefaniwsky
- Section of Gastroenterology, Louisiana State University Health Sciences Center, New Orleans
| | - Matthew Petersile
- Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester
| | - Prashanth Rau
- Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester
| | - Anne Foley
- Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester
| | - David Cave
- Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester
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Garcia-Sanchez C, Pintor-Tortolero J, De la Portilla F. Ileal Dieulafoy's lesion as a rare cause of lower gastrointestinal bleeding associated with inflammatory bowel disease. ANZ J Surg 2021; 91:1042-1043. [PMID: 33999525 DOI: 10.1111/ans.16676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 02/05/2021] [Accepted: 02/06/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Carlos Garcia-Sanchez
- Coloproctology Unit. General and Gastrointestinal Surgery Division, Virgen del Rocío University Hospital, Seville, Spain
| | - Jose Pintor-Tortolero
- Coloproctology Unit. General and Gastrointestinal Surgery Division, Virgen del Rocío University Hospital, Seville, Spain
| | - Fernando De la Portilla
- Coloproctology Unit. General and Gastrointestinal Surgery Division, Virgen del Rocío University Hospital, Seville, Spain
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First Case of Laparoscopic-Endoscopic Management of a Rare Complication After Roux-en-Y Gastric Bypass: Bleeding Dieulafoy's Lesion in the Excluded Duodenal Tract. Obes Surg 2021; 31:3866-3868. [PMID: 33871772 DOI: 10.1007/s11695-021-05432-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 12/26/2022]
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9
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Patnayak R, Patnaik P, Ray M, Das P, Mahapatra D. Dieulafoy's lesion in small intestine. FORMOSAN JOURNAL OF SURGERY 2021. [DOI: 10.4103/fjs.fjs_108_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Malik A, Inayat F, Goraya MHN, Almas T, Ishtiaq R, Malik S, Tarar ZI. Jejunal Dieulafoy's Lesion: A Systematic Review of Evaluation, Diagnosis, and Management. J Investig Med High Impact Case Rep 2021; 9:2324709620987703. [PMID: 33472441 PMCID: PMC7829607 DOI: 10.1177/2324709620987703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/10/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Adnan Malik
- Loyola University Medical Center,
Maywood, IL, USA
| | - Faisal Inayat
- Allama Iqbal Medical College, Lahore,
Punjab, Pakistan
| | | | - Talal Almas
- Royal College of Surgeons in Ireland,
Dublin, Ireland
| | | | - Sohira Malik
- Nishter Medical University, Multan,
Punjab, Pakistan
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11
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Gastric Dieulafoy's lesion with subepithelial lesion-like morphology. Clin J Gastroenterol 2020; 14:71-75. [PMID: 33025344 DOI: 10.1007/s12328-020-01257-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022]
Abstract
Most cases of Dieulafoy's lesion, a rare cause of upper gastrointestinal bleeding, occur in the upper gastric corpus, usually with no edematous bulging or fold convergence around the mucosal defect. This report describes a case of Dieulafoy's lesion with subepithelial lesion (SEL)-like morphology. Endoscopic treatment by hemoclipping was difficult. Because of repeated bleeding, abdominal dynamic contrast computed tomography (CT) was conducted. Results showed a large caliber, tortuous artery branching directly from the celiac artery and feeding into the gastric wall of the gastric fundus. Rupture of this vessel in the submucosa was thought to be responsible for the SEL-like morphology. All findings indicated endoscopic treatment from the gastric mucosal side was too difficult. Therefore, we treated the lesion using interventional radiology (IR) technique of vascular embolization. If an SEL-like Dieulafoy's lesion cannot be treated by endoscopic hemostasis, then IR might be necessary to treat the vascular anomaly.
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12
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Orron DE, Bloom AI, Neeman Z. The Role of Transcatheter Arterial Embolization in the Management of Nonvariceal Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2018; 28:331-349. [PMID: 29933779 DOI: 10.1016/j.giec.2018.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nearly 50 years ago, catheter angiography was introduced as a means of both diagnosing and treating nonvariceal upper gastrointestinal bleeding. Technological advances and innovations have resulted in the introduction of microcatheters that, using a coaxial technique, are capable of selecting third-order arterial branches and of delivering a wide array of embolic agents. This article reviews the imaging diagnosis of nonvariceal upper gastrointestinal bleeding, the techniques of diagnostic and therapeutic angiography, the angiographic appearance of the various etiologies of nonvariceal upper gastrointestinal bleeding, the rationale behind case-specific selection of embolic agents as well as the anticipated outcome of transcatheter arterial embolization.
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Affiliation(s)
- Dan E Orron
- Department of Radiology, Carmel Medical Center, Michal Street, Haifa 34362, Israel
| | - Allan I Bloom
- Department of Radiology, Hadassah University Medical Center, Ein Karem, Jerusalem 91120, Israel
| | - Ziv Neeman
- Medical Imaging Institute, Haemek Medical Center, Izhak Rabin Boulevard, Afula 1834111, Israel.
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Inayat F, Amjad W, Hussain Q, Hurairah A. Dieulafoy's lesion of the duodenum: a comparative review of 37 cases. BMJ Case Rep 2018; 2018:bcr-2017-223246. [PMID: 29472423 PMCID: PMC5847980 DOI: 10.1136/bcr-2017-223246] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2018] [Indexed: 12/17/2022] Open
Abstract
Dieulafoy's lesion is an abnormally large, tortuous, submucosal vessel that erodes the overlying epithelium without primary ulceration or erosion. The lesion predominantly occurs in the proximal stomach but it is also reported in extragastric sites. The pathogenesis and precipitating factors are poorly understood. Patients frequently present with gastrointestinal haemorrhage that can range from being self-limited to massive life threatening. Although there are no standard guidelines, endoscopy has significantly impacted the diagnosis and management. This review outlines our current understanding of the epidemiology of and risk factors for Dieulafoy's lesion of the duodenum, the pathophysiology of this disorder, and currently available approaches to diagnosis and management.
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Affiliation(s)
| | - Waseem Amjad
- Northwell-Long Island Jewish Forest Hills Hospital, Forest Hills, NY, USA
| | | | - Abu Hurairah
- SUNY Downstate Medical Center, Brooklyn, NY, USA
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Inayat F, Ullah W, Hussain Q, Abdullah HMA. Dieulafoy's lesion of the colon and rectum: a case series and literature review. BMJ Case Rep 2017; 2017:bcr-2017-220431. [PMID: 29070617 DOI: 10.1136/bcr-2017-220431] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Dieulafoy's lesion is a dilated, aberrant, submucosal vessel that erodes the overlying epithelium without obvious ulceration. It is most commonly located in the lesser curvature of the stomach but rare occurrences in extragastric sites have also been reported. Herein, we describe a case series of three patients who presented with lower gastrointestinal bleeding. Colonoscopy revealed a caliber-persistent tortuous submucosal artery protruding into the lumen of the colon or rectum. The patients were diagnosed with Dieulafoy's lesion and primary haemostasis was achieved with the endoscopic haemoclip application. The purpose of this review is to summarise the available data on the pathophysiology, epidemiology, clinical presentation, diagnosis and management of patients with Dieulafoy's lesion of the colon and rectum.
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