Rapid Communication Open Access
Copyright ©2007 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Gastroenterol. Aug 28, 2007; 13(32): 4333-4335
Published online Aug 28, 2007. doi: 10.3748/wjg.v13.i32.4333
Clinical presentation and endoscopic management of Dieulafoy’s lesions in an urban community hospital
Srikrishna Nagri, Suryanarayan Anand, Yashpal Arya
Srikrishna Nagri, Suryanarayan Anand, Department of Gastroenterology, Brooklyn Hospital Center, Brooklyn, NY 11201, United States
Yashpal Arya, Wyckoff Heights Medical Center, Department of Gastroenterology, Wyckoff Heights Medical Center, 374 Stockholm St, Brooklyn, NY 11237, United States
Author contributions: All authors contributed equally to the work.
Correspondence to: Srikrishna Nagri, Department of Gastroenterology, Brooklyn Hospital Center, Brooklyn, NY 11201, United States. krishna1973@yahoo.com
Telephone: +1-347-4264451
Received: May 6, 2007
Revised: May 23, 2007
Accepted: May 31, 2007
Published online: August 28, 2007

Abstract

AIM: To identify rates of occurrence, common clinical and endoscopic features, and to review the outcome of endoscopic management of Dieulafoy’s lesions in the upper gastrointestinal (GI) tract in an urban community hospital setting.

METHODS: Endoscopic data from esophagogastroduodenoscopies (EGDs), done at Wyckoff Heights Medical Center, Brooklyn, NY between 2000 and 2006 were reviewed to identify patients with Dieulafoy’s lesions. Demographic data, medical history, examination findings, lab data, endoscopic findings and details of therapy for patients treated for Dieulafoy’s lesions were reviewed retrospectively.

RESULTS: Dieulafoy’s lesions were documented to be the cause of bleeding in approximately 1% of patients presenting with upper gastrointestinal bleeding, while they were detected in only 2 patients when the indications for EGDs were different from active GI bleeding. When we analyzed EGDs performed in patients above age 65 years presenting with gastrointestinal bleeding, prevalence of Dieulafoy’s lesions approached 10 percent. The most common location of the lesion was the body of stomach (7), followed by the cardia (4) and the esophagus (2). One patient had this lesion in the fundus and one patient in the duodenal apex. All patients were initially treated endoscopically with epinephrine injection, in eight cases heater probe was applied following epinephrine and endoscopic clips were applied in two cases. All but one of the patients did well in near and intermediate term follow-up (average follow-up period of 18 mo). One patient died of multi-organ failure during the same hospital stay. Average length hospital stay was 7 d.

CONCLUSION: Community hospital gastroenterologists and endoscopists should be aware that Dieulafoy's lesions are an uncommon cause of upper GI bleeding among elderly patients. Early accurate diagnosis through emergent endoscopy and endoscopic therapy, especially in patients with multiple co-morbid conditions, can be very effective and life saving.

Key Words: Dieulafoy’s lesion, Gastrointestinal bleeding, Community Hospital, Endoscopic treatment, Obscure GI bleeding



INTRODUCTION

Dieulafoy’s lesion consists of a small submucosal artery that protrudes through a tiny mucosal defect anywhere in gastrointestinal tract and is reported to be an uncommon, but important cause of major gastrointestinal bleeding especially in the elderly. Dieulafoy’s lesion was first described by Gallard in 1884 and later named for the French surgeon Dieulafoy. The majority of Dieulafoy’s lesions occur in the proximal stomach, but they have also been reported in the esophagus, small and large bowel[1-3]. Typically, diagnosis is made by endoscopy where therapeutic endoscopy is the treatment of choice[4-7].

This study describes the clinical presentation and endoscopic management of 15 consecutive cases of Dieulafoy’s lesion in Wyckoff Heights Medical Center in Brooklyn NY, an urban community hospital, between years 2000 and 2006. This study shows that Dieulafoy’s lesion is a frequent finding among elderly patients presenting with massive upper gastrointestinal bleeding in a community hospital setting and outcomes of management are similar to published results from tertiary care centers.

MATERIALS AND METHODS

Endoscopic data from emergent esophagogastroduodenoscopies (EGDs) done at Wyckoff Heights Medical Center, Brooklyn, NY between 2000 and 2006 for GI bleeding were reviewed. All the cases were performed by 3 board certified gastroenterologists with more than 10 years of experience. EGD report database was searched for endoscopic findings of Dieulafoy’s lesion during this period. The study was reviewed and approved by our Institutional review board. Endoscopic diagnosis of Dieulafoy’s lesion is based on following published criteria[8], (a) active arterial spurting, oozing of blood from minute mucosal defect (less than 3 mm), (b) visualization of protruding vessel with or without active bleeding within a minute mucosal defect or normal appearing mucosa or, (c) densely adherent clot with a narrow point of attachment to a minute mucosal defect or normal appearing mucosa. Demographic data, medical history, examination findings, lab data, endoscopic findings and details of therapy of patients with Dieulafoy’s lesions obtained from their medical charts were reviewed retrospectively.

RESULTS

Results of analysis of EGDs performed for acute gastrointestinal bleeding in Wyckoff Heights Medical Center between June 2000 and September 2006 are shown in Table 1. Dieulafoy’s lesion was documented to be the cause of bleeding in approximately 1% of patients presenting with upper gastrointestinal bleeding, while it was detected in only 2 patients when the indication was other than active GI bleeding. When we analyzed EGDs performed in patients above age 65 years presenting with gastrointestinal bleeding, prevalence of Dieulafoy’s lesions approached 10 percent (12/123). Mean age of the patients was 79 (SD 8.4), the youngest patient was 61 years old, while the oldest was 92. Six of the 15 patients were female. Thirteen of the 15 patients presented with overt acute gastrointestinal bleeding with hypotension and tachycardia requiring blood transfusion. Mean transfusion requirement was three units of packed red cells. Nine patients presented with hematemesis, one had melena, two had melena and hematemesis, and one had hematochezia alone. Two had anemia with occult gastrointestinal bleeding with no history of overt bleeding. Average hemoglobin at presentation was 9.5 gm (SD 1.5). Summary of patient characteristics and endoscopic findings are shown in Table 2. The most common location of the lesion was the body of stomach (7), followed by cardia (4) and esophagus (2). One patient had this lesion in the fundus and one patient in the duodenal apex. All the cases were identified on index endoscopy. All of the patients were initially treated endoscopically with epinephrine injection (1:10000 dilution) and in 8 cases heater probe was applied following epinephrine. In two patients endoclips were used. Five patients underwent repeat procedures during the same hospital admission, two of them for rebleeding and the others to confirm the initial findings. Both of the rebleeding patients had heater probe applied during the first endoscopy and probe application was repeated during the subsequent endoscopy to successfully control bleeding. The most often reported additional findings were hiatal hernia (4) and antral erythema (8). All the patients had comorbidities, most common being hypertentsion followed by coronary artery disease and type 2 diabetes. All but one of the patients did well in near and intermediate term follow-up (average follow-up period of 18 mo). Follow up data was also obtained from chart-review. One patient died of multiorgan failure during the same hospital stay. Average length hospital stay was 7 d.

Table 1 Analysis of EGDs findings performed at Wyckoff Heights Medical Center between June 2000 and September 2006.
FindingsHematemesisand or Melena(Total 834)Melena(Total 460)Hematochezia(Total 330)All Indications(14 000)
AVM3102N/A
Esophagitis20612263N/A
Gastritis589360281N/A
MW tear18222N/A
Tumor940N/A
Ulcer24519871N/A
Varices1284515N/A
Dieulafoy’s Lesion111115
Table 2 Summary of 15 cases with Dieulafoy’s Lesion treated at Wyckoff Heights Medical Center between June 2000 and September 2006.
PatientAge (yr)Hgb atPresentation(gm/dL)Location ofDieulafoy’sLesionEndoscopicTreatment
1767.6EsophagusEpinephrine
2817.9EsophagusEpi + Heater Probe
38711.2Cardia of StomachEpinephrine
4909.8Body of StomachEpinephrine
59210Cardia of StomachEpinephrine
67811.2Fundus of StomachEpi + Heater Probe
7687Body of StomachEpi + Heater Probe
87310.3Body of StomachEpi + Heater Probe
97911.3Body of StomachEpi + Heater Probe
10719.9Body of StomachHeater Probe
116111.2Body of StomachEpi + Heater Probe
12848.8Body of StomachEpi + Heater Probe
13807.8DuodenumEpinephrine
14828.7FundusEpi + Endoclip
15869FundusEpi + Endoclip
DISCUSSION

The pathogenesis of Dieulafoy’s lesion is not clearly understood, but elongation and tortuosity of a submucosal artery associated with aging may be a factor. Histological description of a Dieulafoy’s lesion shows an artery of 1-3 mm in diameter which is ten times the diameter of a normal submucosal capillary[9].

Dieulafoy’s lesion is an important, but uncommon cause of massive GI bleeding especially from the upper GI tract. These lesions can easily be missed on endoscopy unless the lesion is actively bleeding because these vessels are normally retracted. Studies have described Dieulafoy’s lesion as the cause of upper GI bleeding in 1%-5.8% of cases. In our series, 0.1% of EGDs showed this lesion when all the indications for EGD were included (15 of 14 000) as opposed to about 1% in patients presenting with upper GI bleeding (13 of approximately 1200). Patients affected are typically elderly with significant comorbid conditions. Gender variation was noted (slight male to female predominance).

There have been several endoscopic modalities used successfully to treat Dieulafoy’s lesions. Thermal and/or mechanical methods, hemoclipping and heater probe had better results in retrospective as well as prospective trials[10-12]. Endoscopic hemoclip application, endoscopic band ligation, heater probe application, Nd:YAG, with or without injection therapy have all been shown to be effective in various studies. Initial hemoclip therapy was mostly successful (94.1%-95.2%) with a low recurrence rate[13-15]. Endoscopic heater probe and endoscopic band ligation had similar results[16]. Endoscopic sclerotherapy also had good results in one study[17]. If endoscopic therapy fails, management with other options like angiography with embolization or surgery is indicated. Wedge resection is the surgical procedure of choice. Recurrences can occur, though very rare[13-16]. Long-term results were excellent for endoscopic methods of therapy[16-19]. Mortality was generally low with prompt diagnosis and treatment but one study reported higher mortality due to comorbidities and higher age[20].

Clinical features and management outcome of our series of patients with Dieulafoy’s lesion from an urban community hospital were similar to results reported in the literature. One percent of patients presenting with upper GI bleeding were diagnosed with this condition. The patients were elderly with multiple comorbid conditions. The diagnosis of this lesion was increased sharply if the indication was active upper GI bleeding in elderly patients. Standard therapy with epinephrine and heater probe coagulation of the lesion was very effective and resulted in a good patient outcome. Although injection therapy alone with epinephrine was used in five patients with successful outcome, it is considered suboptimal treatment based on current literature and is not recommended. Based upon our experience endoclip application is the optimal treatment modality for these lesions. Initial injection with epinephrine did not interfere with the application of endoclips.

Based upon these results we conclude that community hospital gastroenterologists and endoscopists should be aware that Dieulafoy's lesions are an uncommon, but important finding among elderly patients with upper GI bleeding. Early accurate diagnosis through emergent endoscopy and therapy, especially in patients with multiple comorbid conditions, can be very effective and life saving.

Footnotes

S- Editor Liu Y L- Editor Rippe RA E- Editor Yin DH

References
1.  Romãozinho JM, Pontes JM, Lérias C, Ferreira M, Freitas D. Dieulafoy's lesion: management and long-term outcome. Endoscopy. 2004;36:416-420.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 47]  [Cited by in F6Publishing: 38]  [Article Influence: 2.6]  [Reference Citation Analysis (0)]
2.  Enns R. Dieulafoy's lesions of the rectum: a rare cause of lower gastrointestinal bleeding. Can J Gastroenterol. 2001;15:541-545.  [PubMed]  [DOI]  [Cited in This Article: ]
3.  Blecker D, Bansal M, Zimmerman RL, Fogt F, Lewis J, Stein R, Kochman ML. Dieulafoy's lesion of the small bowel causing massive gastrointestinal bleeding: two case reports and literature review. Am J Gastroenterol. 2001;96:902-905.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 34]  [Cited by in F6Publishing: 29]  [Article Influence: 1.6]  [Reference Citation Analysis (0)]
4.  Stark ME, Gostout CJ, Balm RK. Clinical features and endoscopic management of Dieulafoy's disease. Gastrointest Endosc. 1992;38:545-550.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 82]  [Cited by in F6Publishing: 38]  [Article Influence: 2.7]  [Reference Citation Analysis (0)]
5.  Parra-Blanco A, Takahashi H, Méndez Jerez PV, Kojima T, Aksoz K, Kirihara K, Palmerín J, Takekuma Y, Fuijta R. Endoscopic management of Dieulafoy lesions of the stomach: a case study of 26 patients. Endoscopy. 1997;29:834-839.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 66]  [Cited by in F6Publishing: 62]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
6.  Reilly HF, al-Kawas FH. Dieulafoy's lesion. Diagnosis and management. Dig Dis Sci. 1991;36:1702-1707.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 88]  [Cited by in F6Publishing: 30]  [Article Influence: 2.9]  [Reference Citation Analysis (0)]
7.  Lin HJ, Lee FY, Tsai YT, Lee SD, Lee CH, Kang WM. Therapeutic endoscopy for Dieulafoy's disease. J Clin Gastroenterol. 1989;11:507-510.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 43]  [Cited by in F6Publishing: 36]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
8.  Norton ID, Petersen BT, Sorbi D, Balm RK, Alexander GL, Gostout CJ. Management and long-term prognosis of Dieulafoy lesion. Gastrointest Endosc. 1999;50:762-767.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 116]  [Cited by in F6Publishing: 41]  [Article Influence: 5.3]  [Reference Citation Analysis (0)]
9.  Lee YT, Walmsley RS, Leong RW, Sung JJ. Dieulafoy's lesion. Gastrointest Endosc. 2003;58:236-243.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 123]  [Cited by in F6Publishing: 94]  [Article Influence: 6.5]  [Reference Citation Analysis (0)]
10.  Chung IK, Kim EJ, Lee MS, Kim HS, Park SH, Lee MH, Kim SJ, Cho MS. Bleeding Dieulafoy's lesions and the choice of endoscopic method: comparing the hemostatic efficacy of mechanical and injection methods. Gastrointest Endosc. 2000;52:721-724.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 115]  [Cited by in F6Publishing: 103]  [Article Influence: 5.5]  [Reference Citation Analysis (0)]
11.  Kasapidis P, Georgopoulos P, Delis V, Balatsos V, Konstantinidis A, Skandalis N. Endoscopic management and long-term follow-up of Dieulafoy's lesions in the upper GI tract. Gastrointest Endosc. 2002;55:527-531.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 38]  [Cited by in F6Publishing: 36]  [Article Influence: 1.9]  [Reference Citation Analysis (0)]
12.  Cheng CL, Liu NJ, Lee CS, Chen PC, Ho YP, Tang JH, Yang C, Sung KF, Lin CH, Chiu CT. Endoscopic management of Dieulafoy lesions in acute nonvariceal upper gastrointestinal bleeding. Dig Dis Sci. 2004;49:1139-1144.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 22]  [Cited by in F6Publishing: 18]  [Article Influence: 1.2]  [Reference Citation Analysis (0)]
13.  Ljubicic N. Efficacy of endoscopic clipping and long-term follow-up of bleeding Dieulafoy's lesions in the upper gastrointestinal tract. Hepatogastroenterology. 2006;53:224-227.  [PubMed]  [DOI]  [Cited in This Article: ]
14.  Katsinelos P, Paroutoglou G, Mimidis K, Beltsis A, Papaziogas B, Gelas G, Kountouras Y. Endoscopic treatment and follow-up of gastrointestinal Dieulafoy's lesions. World J Gastroenterol. 2005;11:6022-6026.  [PubMed]  [DOI]  [Cited in This Article: ]
15.  Yamaguchi Y, Yamato T, Katsumi N, Imao Y, Aoki K, Morita Y, Miura M, Morozumi K, Ishida H, Takahashi S. Short-term and long-term benefits of endoscopic hemoclip application for Dieulafoy's lesion in the upper GI tract. Gastrointest Endosc. 2003;57:653-656.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 48]  [Cited by in F6Publishing: 41]  [Article Influence: 2.5]  [Reference Citation Analysis (0)]
16.  Park CH, Joo YE, Kim HS, Choi SK, Rew JS, Kim SJ. A prospective, randomized trial of endoscopic band ligation versus endoscopic hemoclip placement for bleeding gastric Dieulafoy's lesions. Endoscopy. 2004;36:677-681.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 69]  [Cited by in F6Publishing: 62]  [Article Influence: 3.8]  [Reference Citation Analysis (0)]
17.  Yilmaz M, Ozütemiz O, Karasu Z, Ersöz G, Günsar F, Batur Y, Aydin A, Tekesin O, Yönetci N, Ilter T. Endoscopic injection therapy of bleeding Dieulafoy lesion of the stomach. Hepatogastroenterology. 2005;52:1622-1625.  [PubMed]  [DOI]  [Cited in This Article: ]
18.  Sone Y, Kumada T, Toyoda H, Hisanaga Y, Kiriyama S, Tanikawa M. Endoscopic management and follow up of Dieulafoy lesion in the upper gastrointestinal tract. Endoscopy. 2005;37:449-453.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 47]  [Cited by in F6Publishing: 39]  [Article Influence: 2.4]  [Reference Citation Analysis (0)]
19.  Skok P. Endoscopic hemostasis in exulceratio simplex-Dieulafoy's disease hemorrhage: a review of 25 cases. Endoscopy. 1998;30:590-594.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 17]  [Cited by in F6Publishing: 20]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
20.  Pointner R, Schwab G, Königsrainer A, Dietze O. Endoscopic treatment of Dieulafoy's disease. Gastroenterology. 1988;94:563-566.  [PubMed]  [DOI]  [Cited in This Article: ]