Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis

Table 4 Key clinical findings in Dieulafoy’s Lesion associated with chronic liver disease

Key findings	Rationale	Ref.
Typically presents with acute severe bleeding	Micropulsatile bleeding produced by rent in an arteriole which is under high pressure	Nojkov et al[31], Luis et al[94]
Bleeding typically painless	Primary vascular event (bursting of a persistent-caliber vessel) without associated inflammation or ulceration	Cappell[29]
Appears at endoscopy as an elevated pigmented protuberance with minimal surrounding erosion and no ulceration	Formed by a caliber-persistent artery that erupts through superficial overlying cells on mucosal surface	Nojkov et al[31], Lee et al[93]
Lesion most commonly located in stomach, typically within 6 cm below the gastroesophageal junction along the lesser curve	This gastric region is not perfused by a submucosal plexus, but instead is perfused directly from tributaries of the right and left gastric arteries	Cappell et al[29], Fockens et al[90], Lee et al[95]
Often (up to 30% of cases) missed at initial esophagogastroduodenoscopy (EGD)	Missed at EGD because lesion is small and inconspicuous	Nojkov et al[31], Chung et al[96]
Incidence of 1.5% among general population of patients with upper GI bleeding		Fockens et al[90], Chaer et al[97]
High (25%) mortality if untreated at EGD, which is reduced to about 10% with endoscopic therapy	High risk of rebleeding if not treated endoscopically. Rebleeding is frequently massive	Romãozinho et al[98]
Dieulafoy’s lesion may be associated with cirrhosis		Akhras et al[91], Baettig et al[92]
Bleeding from a Dieulafoy’s lesion is associated with alcoholism	Alcohol may precipitate DL rupture manifesting as GI bleeding by weakening the dilated (caliber-persistent) arteriolar wall in Dieulafoy’s lesion	Baettig et al[92], Lee et al[95]

GI: Gastrointestinal; EGD: Esophagogastroduodenoscopy.