Dieulafoy-like lesion of the colon presenting with massive lower gastrointestinal bleeding

Esophageal Dieulafoy Lesion: A Rare and Potentially Fatal Entity

A 35-year-old gentleman presented acutely to the emergency department with large volume haematemesis and melena. Following adequate initial resuscitation, the patient underwent emergency upper gastrointestinal endoscopy which revealed a dilated tortuous submucosal vessel which was actively bleeding at the midpoint of the esophagus. This was consistent with a Dieulafoy lesion. However, its position in the midpoint of the esophagus is rare. Our patient recovered well following intervention.

The Diagnostic Dilemma of Dieulafoy's Lesion

Dieulafoy’s lesion (DL) is a relatively rare condition which carries a significantly high risk for mortality. A tortuous large arteriole in the wall of the stomach can result in significant gastrointestinal (GI) hemorrhage which can result in detrimental complications. Although it only accounts for about 1% of all GI bleeding, it has been considered to be one of the most underrecognized conditions. This train of thought may unfortunately be related to the difficulty in its diagnosis. After conducting a Medline search of the medical literature, with a focus on current PubMed articles, a thorough examination of updated diagnostic and treatment approaches was compared. Diagnostic techniques in the analysis and treatment of DLs continue to be limited to this day. Endoscopy remains as the main diagnostic and therapeutic tool; however, it continues to have its limitations. Other alternatives include but are not limited to angiography and surgical interventions which at times can be more successful. Diagnostic improvements and research for the detection of DL continue to advance; however, they remain limited in their capabilities. Further analysis and workup needs to be conducted in order to reduce hospital stay and improve survival.

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.

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.

[Dieulafoy's lesion of the gallbladder as a cause of hemobilia with hemoperitoneum]

Dieulafoy's lesion is an uncommon vascular anomaly causing massive gastrointestinal hemorrhage, characterized by bleeding from an arteriole that protrudes through a tiny mucosal defect. Although Dieulafoy's lesion was initially described in the stomach and upper gastrointestinal tract, cases have also been reported in the colon, rectum and anal canal. We report the first case of Dieulafoy's lesion in the gallbladder, which presented as massive peritoneal bleeding. We describe the clinical and pathological characteristics of this unusual entity, as well as the approach to its diagnosis and treatment.

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.

The use of endoclips in the treatment of nonvariceal gastrointestinal bleeding. Surg Laparosc Endosc Percutan Tech. 2009;19:2-10. [PMID: 19238058 DOI: 10.1097/SLE.0b013e31818e9297]

Acute nonvariceal gastrointestinal bleeding is the most common emergency managed by endoscopists and the endoscopic therapy has generally been recommended as the first-line treatment. Traditionally, endoscopic treatment included injections of epinephrine and sclerosing solutions or the use of thermocoagulation. In the last decade with the introduction of hemoclips and band ligators, we have witnessed a significant improvement in the clinical outcome of nonvariceal gastrointestinal bleeding. Endoclipping is a safe and effective technique that contributes to hemostasis of bleeding lesions of the gastrointestinal tract.

Massive bleeding from a rectal dieulafoy lesion: combined multidetector-row CT diagnosis and endoscopic therapy

Dieulafoy lesion is an uncommon cause of acute gastrointestinal bleeding. The diagnosis is usually carried out endoscopically. We report a 77-year-old woman with rectal Dieulafoy lesion. A recent endoscopic examination missed the lesion because it was small and the bleeding was intermittent. In our case, prompt colonoscopic therapy was allowed after locating the bleeder by multidetector-row computed tomography. On the basis of the success of this procedure, we suggest that an emergent multidetector-row computed tomography could have a role in the management of patients with massive lower gastrointestinal bleeding.

Endoscopic therapy for gastrointestinal bleeding due to Dieulafoy lesion: an analysis of 77 cases

AIM: To assess endoscopic homeostasis method for gastrointestinal bleeding due to Dieulafoy lesion.

METHODS: Seventy-seven patients with gastrointestinal bleeding due to Dieulafoy lesion were treated with the following three kinds of endoscopic homeostasis methods: injecting therapy with aethoxysclerol (36 cases), endoscopic hemoclip homeostasis (21 cases), hemoclip hemostasis in combination with injecting therapy of aethoxysclerol (20 cases). The successful homeostasis rates and complication rates of the three approaches were assessed.

RESULTS: Successful homeostasis rates of the three approaches were 80.6%(29/36), 95.2%(20/21) and 100(20/20), respectively and a significant difference was detected (P < 0.05). 7 cases who failed with injecting therapy of aethoxysklerol were treated with hemoclip hemastasis. 5 cases succeeded and 2 cases failed and underwent further surgical operation. 1 case who failed with hemoclip homeostasis was later treated with injecting therapy of aethoxysklerol and bleeding was controlled. No serious complications including perforation occurred in patients using endoscopic hemostasis method and no re-bleeding occurred during half-year follow-up.

CONCLUSION: Hemoclip hemostasis in combination with injecting therapy of aethoxysklerol is the most effective method for gastrointestinal bleeding due to Dieulafoy lesion.