Efficacy of endoscopic therapy for gastrointestinal bleeding from Dieulafoy’s lesion

Case report: Dieulafoy's lesion as a rare cause of massive gastrointestinal hemorrhage

INTRODUCTION AND IMPORTANCE

Dieulafoy's lesion is a rare but serious cause of gastrointestinal bleeding, typically affecting older adults. It involves an aberrant arteriole eroding the gastric mucosa, resulting in severe, recurrent bleeding that poses diagnostic and management challenges. We present a case report of massive gastrointestinal hemorrhage with hemodynamic instability associated with a Dieulafoy's lesion.

CASE PRESENTATION

A 55-year-old male with no significant medical history presented with gastrointestinal bleeding, showing signs of hematemesis and melena. He was hemodynamically unstable upon admission, with a hemoglobin level of 6 g/dL. After resuscitation and stabilization, an esophagogastroduodenoscopy revealed a 5 mm Dieulafoy lesion in the fundus, treated successfully with hemostatic clips. The patient had an uneventful recovery and was discharged on the fourth day, with normal follow-up at one year and no complications.

CLINICAL DISCUSSION

Dieulafoy's lesion, a rare cause of gastrointestinal bleeding, is found in 1-2 % of cases, primarily in males over 60 years old. First described by Dieulafoy, it results from an aberrant arteriole erosion, commonly in the upper stomach. Diagnosis is challenging during active bleeding and often requires multiple endoscopies. Mechanical hemostasis methods during endoscopy are effective, with recurrence rates of 8-10 %. Surgical intervention is reserved for severe, uncontrolled cases.

CONCLUSION

Dieulafoy's lesion, though rare, requires prompt diagnosis and effective endoscopic treatment to manage severe bleeding. Combining hemostatic techniques or surgical options may be necessary to address persistent cases and improve patient outcomes.

The efficacy of sclerotherapy as the initial treatment in patients with bleeding from Dieulafoy's lesion of the upper gastrointestinal tract

BACKGROUND

Dieulafoy's lesion (DL) is a rare and important cause of acute nonvariceal upper gastrointestinal bleeding (ANVUGIB), however, there is a lack of clear guidelines focus on the endoscopic hemostasis treatment for DL. Sclerotherapy, as the ANVUGIB guideline recommended endoscopic hemostasis method, is widely used in clinical practice. The aim of this study is to investigate the efficacy of sclerotherapy as the initial treatment for Dieulafoy's lesion of the upper gastrointestinal tract (UDL).

METHODS

Patients with UDL who underwent the ANVUGIB standard endoscopic hemostasis between April 2007 and January 2023 were enrolled. The endoscopic therapy method was left to the discretion of the endoscopist.

RESULTS

In total, 219 patients were finally obtained, with 74 (33.8%) receiving sclerotherapy and 145 (66.2%) receiving other standard endoscopic therapy. The rebleeding within 30 days was significantly lower in the sclerotherapy group compared to the other standard group (5.8% vs. 16.8%, p = 0.047). There were no significant differences between the two groups in terms of successful hemostasis rate (93.2% vs. 94.5%, p = 0.713), median number of red blood cell transfusions (3.5 vs. 4.0 units, p = 0.257), median hospital stay (8.0 vs. 8.0 days, p = 0.103), transferred to ICU rate (8.1% vs. 6.2%, p = 0.598), the need for embolization or surgery rate (12.2% vs. 9.7%, p = 0.567) and 30-day mortality (0 vs. 2.1%, p = 0.553). In addition, we found no difference in efficacy between sclerotherapy alone and combination (3.1% vs. 8.1%, p = 0.714). Further analysis revealed that thermocoagulation for hemostasis was associated with a higher rate of rebleeding (28.6% vs. 3.1%, p = 0.042) and longer hospital stay (11.5 vs. 7.5 days, p = 0.005) compared to sclerotherapy alone.

CONCLUSION

Sclerotherapy represents an effective endoscopic therapy for both alone and combined use in patients with upper gastrointestinal Dieulafoy's lesion. Therefore, sclerotherapy could be considered as initial treatment in patients with bleeding of UDL.

Diagnosis and Treatment of a Recurrent Bleeding Dieulafoy's Lesion: A Case Report

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.

Massive gastrointestinal haemorrhage caused by pancreatic pseudocyst complicated with Dieulafoy's disease in a child: A case report and review of the literature

BACKGROUND

Pancreatic pseudocyst (PPC) with massive gastrointestinal bleeding is rare, especially in children. Inadvertent intraoperative examination and damage to the gastric mucosa and malformed blood vessels by the fluid content of PPC can lead to massive bleeding, which may endanger the patient's life.

CASE PRESENTATION

Here, we present a case of an 8-year-old boy who was diagnosed with a massive gastrointestinal haemorrhage caused by PPC complicated with Dieulafoy's disease. At his first admission, his complaint was being hit to the stomach by the handlebar while riding bicycle 24 h before admission. After being hospitalized, he was diagnosed with pancreatic injury by abdominal CT. Conservative treatment lasted for 1 month in the Department of Pediatric Surgery. Then, a pancreatic pseudocyst was formed. Under the guidance of ultrasonic endoscopy, cyst puncture and drainage of pseudocysts through the gastric wall were performed. Unexplained hematemesis occurred 8 days after surgery. Emergency gastroscopy was performed, and abnormal submucosal vascular haemorrhage was found at the gastric fundus. Gastric Dieulafoy's disease was diagnosed. The boy underwent gastroscopic titanium clipping of abnormal arteries. He had no complications during the 3-month follow-up. Then, the patient returned to the hospital, and the stent was removed under endoscopy. No bleeding was found, and the patient was discharged. The patient recovered smoothly and was followed up for half a year without any complications, and hematological indicators were normal.

CONCLUSION

Endoscopic ultrasonography-guided gastric puncture and internal drainage of cysts is a safe and effective surgical method for the treatment of pancreatic pseudocysts. However, at the same time, it is necessary to thoroughly and carefully explore the stomach cavity to prevent adverse consequences caused by a missed diagnosis of gastric Dieulafoy's disease or other abnormal abnormalities.

Risk Factors for Rebleeding after Emergency Endoscopic Treatment of Dieulafoy Lesion

Background and Objective: Dieulafoy lesion is a rare, but life-threatening, cause of gastrointestinal hemorrhage, and endoscopic therapy is the preferred first-line treatment. The present study aims to analyze the risk factors for rebleeding after endoscopic hemostasis of gastroduodenal Dieulafoy lesion. Methods. A retrospective review of patients with Dieulafoy lesion who developed acute gastrointestinal bleeding and were treated primarily with endoscopic therapy from September 2014 to April 2019 was conducted. Results. A total of 133 patients with Dieulafoy lesion were included in the present study. The mean age of these patients was 56.05 ± 16.58 years, and 115 patients were male. Among these 133 patients, 26 patients developed rebleeding within 30 days of endoscopic therapy. The 30-day rebleeding rate for pure injection therapy (epinephrine, cyanoacrylate, or lauromacrogol injection alone), nonpure injection therapy (argon plasma coagulation, band ligation, and hemoclip application alone), and combination therapy (combination of any >2 methods) was 45.2%, 12.8%, and 11%, respectively. In the univariable analysis, endoscopic treatment, prothrombin time, gender, Rockall score, and leukocyte count were the risk factors for rebleeding. In the multivariable analysis, pure injection endoscopic treatment, white blood cells (>10 × 109/L), and prothrombin time >12 seconds were the independent risk factors for rebleeding. Conclusion. Patients who undergo pure injection endoscopic treatment and have a high leukocyte count (>10 × 109/L) or elevated prothrombin time (>12 seconds) have an increased risk of rebleeding within 30 days after endoscopic treatment for gastroduodenal Dieulafoy lesion. Combined endoscopic treatment is the most effective therapy to prevent rebleeding in gastroduodenal Dieulafoy lesion.

Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group

DESCRIPTION

This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations.

METHODS

An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional.

RECOMMENDATIONS

Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.

Effectiveness and safety of polidocanol for the treatment of hemangiomas and vascular malformations: A meta-analysis

A meta-analysis was conducted to investigate the efficacy and safety of polidocanol versus other conventional therapies in treating hemangiomas (HMs) and vascular malformations (VMs). Literature search was conducted in the Cochrane, Embase, PubMed, Web of Science, CNKI, CBM, VIP, and WanFang databases until March 5, 2017. A meta-analysis was conducted using Revman 5.3 software. A total of 19 randomized controlled trials (RCTs) involving 1,514 participants met the inclusion criteria. Regarding the effectiveness, statistically significant differences were observed between polidocanol and all the independent treatments (p = .006), but not between polidocanol and pingyangmycin (p = .16). Combination therapy of polidocanol with any other conventional treatments (p = .0001), pingyangmycin (p = .005) or hemoclip (p = .008) elicited a better response compared to treatment with these treatments independently. A meta-analysis on the risk of adverse events (AEs) showed a lower risk for polidocanol versus other treatments, for example, all the conventional treatments used independently (p < .00001) and pingyangmycin (p < .00001). Combination therapy of polidocanol with pingyangmycin also yielded a significantly lower risk of AEs (p < .00001). Polidocanol is at least as effective as other conventional therapies on HMs and VMs (especially venous malformations). The former is much safer. Combining its use with other treatments may produce excellent results. Our study provides strong evidence supporting the use of polidocanol for HMs and VMs.

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.

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.

Improving outcome following life-threatening gastrointestinal bleeding not amenable to endoscopy in an ASA grade 5 patient: lessons learned

We present a 74-year-old woman, who developed massive haematemesis and hypovolaemic shock. Her management was challenging, as the bleeding site could not be identified during oesophagogastroduodenoscopy, she was not fit for a general anaesthesia and not able to lie flat due to heart failure, caused by pericardial effusion. She underwent an emergency laparotomy and gastrotomy under a combined thoracic epidural and lumbar spinal regional anaesthesia in a sitting position, 45° to horizontal plane. The bleeding site was identified as a Dieulafoy lesion on the posterior wall of the stomach and was controlled by under running the lesion. She had an uneventful recovery and is symptom-free post-surgery for a year at present.

Recent advances on the management of patients with non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal bleeding is a common emergency associated with significant morbidity and mortality. The mainstays of therapy include prompt resuscitation, early risk stratification, and appropriate access to endoscopy. Patients with high-risk endoscopic findings should receive endoscopic hemostasis with a modality of established efficacy. The pillar of post-endoscopic therapy is acid-suppression via proton pump inhibitors (PPI), although the optimal dose and route of administration are still unclear. Post-discharge management of patients with peptic ulcers includes standard oral PPI treatment and eradication of Helicobacter pylori infection. The risk of recurrent bleeding should be carefully considered and appropriate gastroprotection should be offered when non-steroid anti-inflammatory drugs, anti-platelet agents, and/or anticoagulation need to be used. This review seeks to survey new evidence in the management of non-variceal upper gastrointestinal bleeding that has emerged in the past 3 years and put it into context with recommendations from recent practice guidelines.

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.