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Khan R, Mahmad A, Gobrial M, Onwochei F, Shah K. The Diagnostic Dilemma of Dieulafoy's Lesion. Gastroenterology Res 2015; 8:201-206. [PMID: 27785297 PMCID: PMC5040527 DOI: 10.14740/gr671w] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Rafay Khan
- Internal Medicine Department, Raritan Bay Medical Center, 530 New Brunswick Avenue, Perth Amboy, NJ 08861, USA
| | - Abdul Mahmad
- Internal Medicine Department, Raritan Bay Medical Center, 530 New Brunswick Avenue, Perth Amboy, NJ 08861, USA
| | - Mark Gobrial
- Internal Medicine Department, Maimonides Medical Center, 4802 10th Ave, Brooklyn, NY 11219, USA
| | - Francis Onwochei
- Internal Medicine Department, Jersey City Medical Center, 355 Grand St, Jersey City, NJ 07302, USA
| | - Kunal Shah
- St. George's University School of Medicine, University Centre, Grenada, West Indies
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Shin HJ, Ju JS, Kim KD, Kim SW, Kang SH, Kang SH, Moon HS, Sung JK, Jeong HY. Risk Factors for Dieulafoy Lesions in the Upper Gastrointestinal Tract. Clin Endosc 2015; 48:228-33. [PMID: 26064823 PMCID: PMC4461667 DOI: 10.5946/ce.2015.48.3.228] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 10/13/2014] [Accepted: 10/19/2014] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Hae Jin Shin
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jong Seok Ju
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Ki Dae Kim
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Seok Won Kim
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sung Hoon Kang
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun Hyung Kang
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hee Seok Moon
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Kyu Sung
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyun Yong Jeong
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
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Jeon HK, Kim GH. Endoscopic Management of Dieulafoy's Lesion. Clin Endosc 2015; 48:112-120. [PMID: 25844338 PMCID: PMC4381137 DOI: 10.5946/ce.2015.48.2.112] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 11/02/2014] [Accepted: 11/03/2014] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Hye Kyung Jeon
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Jamanca-Poma Y, Velasco-Guardado A, Piñero-Pérez C, Calderón-Begazo R, Umaña-Mejía J, Geijo-Martínez F, Rodríguez-Pérez A. Prognostic factors for recurrence of gastrointestinal bleeding due to Dieulafoy's lesion. World J Gastroenterol 2012; 18:5734-8. [PMID: 23155314 PMCID: PMC3484342 DOI: 10.3748/wjg.v18.i40.5734] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 07/26/2012] [Accepted: 07/28/2012] [Indexed: 02/06/2023] Open
Abstract
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.
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5
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Dieulafoy lesions of the GI tract: localization and therapeutic outcomes. Dig Dis Sci 2010; 55:3436-41. [PMID: 20848205 DOI: 10.1007/s10620-010-1385-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 08/02/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Dieulafoy lesions are a rare cause of gastrointestinal hemorrhage with a striking presentation because of rapid blood loss. Endoscopic therapy is usually successful at achieving primary hemostasis, but the best mode of endoscopic intervention is not clear, and outcomes relating to variables such as gender, medication, alcohol, and smoking are not known. We reviewed the clinical experience with Dieulafoy lesions at our institution, focusing on clinico-epidemiological features, management practices, and also survival. METHODS A retrospective and prospective cohort of patients with Dieulafoy lesions who underwent endoscopy from January 2004 through April 2009 were studied and detailed clinical data were abstracted and collected. RESULTS We identified 63 patients with a Dieulafoy lesion. The majority were male with an average age 58 years. Hematemesis and melena were the most common presenting symptoms. Almost half the patients were on anticoagulation medication. Most of the Dieulafoy lesions occurred in the upper GI tract, and mostly in the stomach. Single-modality endoscopic therapy was used as frequently as combination therapy, and both were effective, as primary hemostasis was achieved in 92% of cases. There were 11 deaths overall; death due to Dieulafoy lesion exsanguination was attributed to three patients. CONCLUSIONS Dieulafoy lesions occurred in younger patients than previously reported, and were more frequently diagnosed in males. Most DL lesions occurred in the upper GI tract. Primary hemostasis with endoscopic therapy was highly successful. Overall mortality was 17%, and associated with co-morbidities, and not with medical history, gender, age, or medication.
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6
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Macrì A, Saladino E, Versaci A, Basile A, Lamberto S, De Francesco F, Familiari L, Famulari C. Massive bleeding from a Dieulafoy's lesion of the duodenum successfully treated with "adjuvant" transarterial embolization and endoscopic laser coagulation. Acta Chir Belg 2010; 110:208-209. [PMID: 20514835 DOI: 10.1080/00015458.2010.11680599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Dieulafoy's lesions, very rare in the duodenum, are considered uncommon causes of gastrointestinal bleeding and occur from pinpoint non-ulcerated arterial lesions. We report a case of Dieulafoy's lesion of the duodenum, in which a first diagnostic approach by using endoscopy and angiography was not successful; then, due to a high operative risk, we performed an "adjuvant" embolization of the gastroduodenal artery with the aim of reduce the flow through the artery, allowing the endoscopic localization of the site of bleeding and subsequent effective treatment. To our knowledge, this is the first case reported in the literature, in which, without aetiological diagnosis, an "adjuvant" embolization of the gastroduodenal artery was performed with the aim of reduce the blood flow in the duodenal wall, permitting an easier endoscopic diagnosis of Dieulafoy's duodenal lesion and successful treatment with laser coagulation.
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Affiliation(s)
- A Macrì
- General Surgery Unit, University of Messina, Ospedale Farrarotto Catania, Italy.
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7
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Khan MI, Baqai MT, Baqai MF, Mufti N. Exsanguinating upper GI bleeds due to Unusual Arteriovenous Malformation (AVM) of stomach and spleen: a case report. World J Emerg Surg 2009; 4:15. [PMID: 19409093 PMCID: PMC2687422 DOI: 10.1186/1749-7922-4-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 05/01/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In this paper we are reporting one case of exsanguinating upper gastrointestinal tract (GIT) bleed requiring massive blood transfusion and immediate life saving surgery. CASE PRESENTATION A 30 years old female, 12 weeks pregnant was referred to our hospital from the earth-quake affected area of Kashmir with history of upper abdominal pain, haematemesis and melaena for one week. After stabilizing the patient, upper gastro-intestinal endoscopy was performed. It revealed gastric ulcer just distal to the gastro-esophageal junction on the lesser curvature. Biopsy from the ulcer edge led to profuse spurting of the blood and patient went into state of shock. Immediate resuscitation led to rebleeding and recurrence of post haemorrahagic shock. CONCLUSION The patient was immediately explored and total gastrectectomy with splenectomy concluded as life saving procedure. A review of literature was conducted to make this report possible.
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Affiliation(s)
- Mohammad Iqbal Khan
- Department of surgery, Islamic International Medical College, Rawalpindi, Pakistan.
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8
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Siddiqui T, Parnaby C, Mackay C. Duodenal Dieulafoy's Lesion: A Case Report. Scott Med J 2008. [DOI: 10.1258/rsmsmj.53.3.57e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Dieulafoy's lesion is an uncommon but important cause of recurrent upper gastrointestinal bleeding. Extragastric location of Dieulafoy's lesion is extremely rare. We report a case of upper gastrointestinal haemorrhage due to Dieulafoy's lesion of the duodenum and discuss the management of this extremely uncommon entity.
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Affiliation(s)
- T Siddiqui
- Department of General Surgery, The Southern General Hospital, Glasgow, Scotland, UK
| | - C Parnaby
- Department of General Surgery, The Southern General Hospital, Glasgow, Scotland, UK
| | - C Mackay
- Department of General Surgery, The Southern General Hospital, Glasgow, Scotland, UK
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9
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Linhares MM, Filho BH, Schraibman V, Goitia-Durán MB, Grande JCD, Sato NY, Lourenço LG, Lopes-Filho GDJ. Dieulafoy lesion: endoscopic and surgical management. Surg Laparosc Endosc Percutan Tech 2006; 16:1-3. [PMID: 16552369 DOI: 10.1097/01.sle.0000202191.59322.5f] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Marcelo M Linhares
- Department of Surgical Gastroenterology, Federal University of São Paulo, EPM-UNIFESP, Brazil.
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10
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Ho KM. Use of Sengstaken-Blakemore tube to stop massive upper gastrointestinal bleeding from Dieulafoy's lesion in the lower oesophagus. Anaesth Intensive Care 2005; 32:711-4. [PMID: 15535501 DOI: 10.1177/0310057x0403200520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Massive upper gastrointestinal bleeding from Dieulafoy's lesion in the gastrointestinal tract is uncommon. The use of the Sengstaken-Blakemore tube in acute gastrointestinal bleeding has become less common since endoscopic sclerotherapy and banding procedures have become widely available. The successful use of a Sengstaken-Blakemore tube to control acute massive upper gastrointestinal bleeding from a Dieulafoy's lesion in the lower oesophagus in an elderly man with severe coronary artery disease and heart failure is described.
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Affiliation(s)
- K M Ho
- Department of Anaesthesia & Intensive Care, North Shore Hospital, Auckland, New Zealand
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11
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Abstract
BACKGROUND Dieulafoy's lesion is a rare cause of gastrointestinal haemorrhage. It has traditionally been treated either endoscopically or with open surgery. AIM To describe a case treated by arterial embolization. RESULTS Initially the patient was embolized with Gelfoam pledgets but re-bled at 7 days, the procedure was repeated with fibre coils, there was no further bleeding. CONCLUSION Arterial embolization is being used increasingly as a first line of treatment as it is fast and minimally invasive with few complications.
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Affiliation(s)
- N Scaramuzzi
- Department of Surgery, Beaumont Hospital, Dublin, Ireland
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12
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Affiliation(s)
- Yuk Tong Lee
- Department of Medicine, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, N.T., Hong Kong
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13
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Affiliation(s)
- Rabih A Chaer
- Department of Surgery, Division of General Surgery, The University of Illinois College of Medicine at Chicago, Chicago, IL 60612, USA
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14
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Azimuddin K, Stasik JJ, Rosen L, Riether RD, Khubchandani IT. Dieulafoy's lesion of the anal canal: a new clinical entity. Report of two cases. Dis Colon Rectum 2000; 43:423-6. [PMID: 10733128 DOI: 10.1007/bf02258313] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- K Azimuddin
- Department of Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania 18105-1556, USA
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15
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Siafakas C, Fox VL, Nurko S. Use of octreotide for the treatment of severe gastrointestinal bleeding in children. J Pediatr Gastroenterol Nutr 1998; 26:356-9. [PMID: 9523876 DOI: 10.1097/00005176-199803000-00022] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- C Siafakas
- Combined Program In Pediatric Gastroenterology and Nutrition, Children's Hospital, Boston, MA 02115, USA
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16
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Holten I, Tait N. Dieulafoy's ulcer: a palpable entity? THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1992; 62:815-7. [PMID: 1445064 DOI: 10.1111/j.1445-2197.1992.tb06926.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Two cases of Dieulafoy's ulcer are reported. Diagnosis was delayed but successful surgical treatment was achieved once the lesion was located by palpation.
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Affiliation(s)
- I Holten
- Craniofacial Unit, Royal Adelaide Children's Hospital, Canberra, Australian Capital Territory
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17
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Abstract
The experience of a specialized management team using urgent endoscopy in the management of acute gastrointestinal bleeding from Dieulafoy's disease is presented. Dieulafoy's disease was found in 19 of 1124 consecutive patients with upper gastrointestinal bleeding. Most patients with Dieulafoy's disease were elderly men with severe acute upper gastrointestinal hemorrhage. Endoscopic diagnosis was possible in all patients, but required multiple endoscopies in 37%. The lesions were in the proximal stomach (79%) and duodenal bulb (21%). Endoscopic therapy included epinephrine injection, then heater probe coagulation in 17 patients, bipolar electrocoagulation in 1, and Nd:YAG laser photocoagulation in 1. Endoscopic therapy was successful in 18 patients (95%); one patient had successful surgery after endoscopic therapy failed. There were no deaths due to bleeding and no endoscopic complications. Dieulafoy's disease is an unusual cause of acute gastrointestinal bleeding. Endoscopic diagnosis is sometimes difficult, but primary endoscopic therapy is safe, successful, and should be attempted.
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Affiliation(s)
- M E Stark
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota 55905
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18
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Abstract
A review of 177 cases of upper gastrointestinal hemorrhage due to Dieulafoy's lesion is reported. Dieulafoy's lesion is frequently responsible for severe and recurrent upper gastrointestinal hemorrhage. The lesion was predominantly found in the proximal stomach. Repeat endoscopies were needed in 33% of the patients in order to make the correct diagnosis. When preoperative diagnosis and localization were made, surgery was an effective therapeutic modality. Therapeutic endoscopy was successful in achieving permanent hemostasis in 85% of the reported cases. Re-treatment was needed in an additional 10% and surgical therapy in 5% of the cases. Therapeutic endoscopy should be considered initially in all patients. Surgical intervention and angiography with embolization may be effective options if endoscopic therapy is unsuccessful.
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Affiliation(s)
- H F Reilly
- Department of Medicine, Georgetown University Medical Center, Washington, D.C. 20007
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19
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Storey DW. Endoscopic cautery using the heater probe as an alternative to operation for massive gastroduodenal haemorrhage. GASTROENTEROLOGIA JAPONICA 1991; 26 Suppl 3:66-70. [PMID: 1884963 DOI: 10.1007/bf02779266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Endoscopic cautery using the heater probe has been used by the author since 1981 for treatment of acute gastroduodenal haemorrhage. The technique has been used as an alternative to immediate operation in 175 patients who had clearly demonstrated a need for intervention. All 175 had suffered recurrent haemorrhage in hospital to a blood transfusion requirement of at least 3 litres. Ulcer patients were selected by being over 60 yrs old or otherwise unfit for operation. Early experience showed that the technique was not reliable for patients bleeding from large posterior duodenal ulcers, so 35 old or sick patients with duodenal ulcer were excluded from the series. There were no exclusions with patients bleeding from lesions proximal to the pylorus, and 82% of these were successfully treated. Even with avoidance of large posterior ulcers, only 47% of duodenal ulcer patients were able to safely avoid an operation. It is concluded that heater probe cautery can replace emergency operation in most patients bleeding from gastric lesions, but it has a limited role for patients bleeding from duodenal ulcer.
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Affiliation(s)
- D W Storey
- Department of Upper Gastrointestinal Surgery and Parenteral Nutrition, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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20
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Eidus LB, Rasuli P, Manion D, Heringer R. Caliber-persistent artery of the stomach (Dieulafoy's vascular malformation). Gastroenterology 1990; 99:1507-10. [PMID: 2210260 DOI: 10.1016/0016-5085(90)91183-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Caliber-persistent artery of the stomach (also known as cirsoid aneurysm, Dieulafoy's lesion, and submucosal arterial malformation) is clinically manifested as recurrent, massive, often fatal hematemesis. The lesion often is not seen endoscopically. Left gastric angiography in one patient with hematemesis showed a convoluted and ectatic artery in the gastric fundus, which proved to be caliber-persistent artery of the stomach on pathological examination. The tortuosity of the abnormal vessel in this condition has been attributed to artefactual contraction of the stomach following excision and formalin fixation. This is the first reported case in which a pathologically proven lesion has been clearly visualized by angiography. This demonstrates that the submucosal vessel is truly and not artifactually sinuous. It is proposed that angiographic demonstration of a nontapering, convoluted artery in the territory of the left gastric artery is highly suggestive of caliber-persistent artery of the stomach.
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Affiliation(s)
- L B Eidus
- Department of Pathology, Ottawa General Hospital, University of Ottawa, Ontario, Canada
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21
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Abstract
Dieulafoy's lesion or cirsoid aneurysm is a rare cause of massive upper gastrointestinal hemorrhage. Historically cirsoid aneurysm most often occurs in the stomach, but has been reported to occur in the jejunum. In this paper, four cases are presented that are felt to represent the first documented cases of cirsoid aneurysm involving the duodenum. At endoscopy, the appearance of Dieulafoy's lesion may range from a pinpoint dot, clot, or tortuous vessel, to blood oozing or spurting from normal mucosa. A shallow defect may be present that can give the appearance of a partially healed peptic ulcer. Previous histologic studies have shown a wide-caliber-persistent artery with intimal thickening, sclerosis, and medial muscular hypertrophy. Once the diagnosis is made, surgical intervention utilizing simple ligation of the involved vessel results in cessation of recurrent hemorrhage. Dieulafoy's lesion is probably more common than the previous literature would suggest. The lesion needs to be considered in the clinical setting of the patient with massive upper gastrointestinal hemorrhage, a paucity of symptoms, and negative findings on barium studies, endoscopy, and exploratory laparotomy.
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Affiliation(s)
- S A McClave
- Department of Medicine, University of Louisville, School of Medicine, Kentucky 40292
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