Bleeding Dieulafoy's lesions and the choice of endoscopic method: Comparing the hemostatic efficacy of mechanical and injection methods

doi:10.1067/mge.2000.108040

Gastrointestinal Endoscopy

Volume 52, Issue 6, December 2000, Pages 721-724

https://doi.org/10.1067/mge.2000.108040 Get rights and content

Abstract

Background: Dieulafoy's lesion has unique endoscopic and histopathologic characteristics. This is a clinical trial of endoscopic therapy in 24 patients with Dieulafoy's lesions. Methods: Patients were divided into 2 groups according to initial endoscopic treatment method. Data were analyzed with respect to clinical and endoscopic characteristics as well as outcomes. The 24 patients were evenly divided into mechanical (9 hemoclipping, 3 band ligation) and injection groups (12). Results: The average number of therapeutic endoscopic sessions needed to achieve permanent hemostasis for the mechanical and injection groups were 1.17 and 1.67, respectively. Initial hemostasis was achieved in 91.7% of patients undergoing mechanical therapy and 75% of those undergoing injection therapy, with none in the former group needing subsequent surgery in comparison to 17% of the latter group.The rate of recurrent bleeding in the mechanical therapy group was significantly lower in comparison to the injection therapy group (8.3% versus 33.3%, p < 0.05). Conclusions: Higher efficacy in terms of initial hemostasis and less recurrent bleeding was achieved by mechanical hemostatic therapy with hemoclip and band ligation compared with injection therapy. Endoscopic mechanical therapy is recommended as effective for bleeding Dieulafoy's lesions. (Gastrointest Endosc 2000;52:721-4.)

Section snippets

Patients and methods

Between January 1995 and July 1998, 812 patients with acute GI bleeding were admitted to our endoscopy unit. Twenty-eight patients who had endoscopic criteria for Dieulafoy's lesion (as described above) were included and treated by therapeutic endoscopy. However, of these, 2 patients did not undergo follow-up endoscopy; 1 refused and 1 was transferred to another hospital. One patient was diagnosed by repeat endoscopy to have a gastric varix, and another patient was diagnosed by operative

Clinical characteristics

There were no significant differences between the 2 groups with respect to initial mean hemoglobin values or the mean number of units of blood transfused during admission (Table 1).

. Clinical characteristics for mechanical and injection treatment groups

Empty Cell	Mechanical (n = 12)	Injection (n = 12)	p Value
Age (yr) (SD)	53.9 (14.4)	52.6 (14.9)	0.83
Gender (M:F)	11:1	10:2	0.44
Hemoglobin (gm/dL) (SD)	8.8 (3.3)	8.5 (2.1)	0.79
Transfusion (unit) (SD)	4.75 (3.2)	4.67 (3.1)	0.95
No. of endoscopic sessions	1.17	1.67	0.17
Total

Discussion

With the advent of endoscopic techniques, management of Dieulafoy's lesions has been achieved by endoscopic methods in contrast to dependency in the past on surgical procedures. Endoscopic hemostatic methods may be divided into 3 groups: thermal, regional injection, and mechanical. Each method has both advantages and disadvantages related to the hemostatic mechanism and the technical procedure itself, and varying results have been reported. The results of endoscopic hemostatic therapies depend

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Dieulafoy's lesion, a rare but life-threatening condition accounting for a small percentage of acute gastrointestinal bleeding cases, has historically posed diagnostic and therapeutic challenges.
In this article, we present two cases that required surgical intervention due to unsuccessful attempts with endoscopy. Case 1 involved a 40-year-old patient with a history of treated duodenal ulcers, while Case 2 featured a 74-year-old woman with no notable medical history. Both patients exhibited severe bleeding, necessitating urgent surgical procedures. The surgical approach involved wide gastrotomy, careful inspection, and successful suturing of the bleeding vessel.
Dieulafoy lesions, discovered by French surgeon Georges Dieulafoy in 1885, constitute 1–2 % of acute gastrointestinal bleeding cases. These anomalies involve enlarged submucosal arteries, predominantly in the stomach, but occurrences in other sites are documented. Endoscopic methods, surpassing surgical intervention, are preferred for treatment, boasting success rates over 90 %. Surgical measures become a last resort for uncontrolled bleeding, with laparoscopic surgery emerging as a minimally invasive alternative, facilitated by various intra-operative localization techniques. Laparoscopic wedge resection, in particular, exhibits lower re-bleeding rates than traditional oversewing methods, although feasibility depends on lesion location.
While endoscopic methods are preferred, surgery remains a vital option when bleeding persists or endoscopic intervention fails. This report highlights the significance of surgical management in selected cases of Dieulafoy's lesion.
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Dieulafoy's lesion is a rare entity, normally present in the stomach and more rarely in the colon, and it is responsible for 1% to 5% of acute gastrointestinal bleeding cases. Its true incidence may be underrated, since most cases are asymptomatic and difficult to diagnose despite endoscopic advances. We present a clinical case of acute gastrointestinal bleeding due to Dieulafoy's lesion in the cecum.
An 85-year-old woman presented with a clinical condition of haematochezia associated with anaemia and haemodynamic instability, needing blood transfusion. Colonoscopy demonstrated a Dieulafoy's lesion in the cecum with active bleeding, and haemostasis was performed successfully with localized adrenaline injection and haemostatic clip placement. Hospitalization occurred without further complications.
The diagnosis of Dieulafoy's lesion is difficult because it is a rare condition and thus, usually not included in the differential diagnosis of gastrointestinal bleeding. Its endoscopic diagnostic and therapeutic approach is the standard method in the event of an acute gastrointestinal bleeding episode, with greater efficiency with the combined use of haemostatic techniques. Surgery is necessary in less than 5% of cases when bleeding is not effectively controlled by endoscopic or angiographic techniques.
It is essential to be aware of this lesion as a possible cause of gastrointestinal bleeding and differentiate it from other causes. Advances in endoscopy have increased the rate of diagnosis of these lesions and reduced their associated mortality.
Dieulafoy's lesion of the upper GI tract: a comprehensive nationwide database analysis
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We sought to determine the incidence, risk factors, and treatment outcomes of Dieulafoy’s lesion of the upper GI tract (UDL) hemorrhage among adult patients in the United States.
UDL and non-Dieulafoy upper GI bleeding (UGIB) were identified from the Nationwide Inpatient Sample and Nationwide Readmission Database using International Classification of Diseases, Tenth Revision, Clinical Modification and Procedure Coding System codes. Multivariate logistic (binary) and linear (continuous) regressions were used to model dependent variables.
The incidence of UDL hemorrhage was 1.6 of 100,000 persons. Patients with UDL and UGIB who required endoscopic therapeutic intervention had similar in-hospital (adjusted odds ratio [aOR], .77; 95% confidence interval [CI], .42-1.43; P = .41) mortality rates. UDL was associated with more severe systemic illness, including higher rates of mechanical ventilation (aOR, 1.52; 95% CI, 1.07-2.15; P < .05), hypovolemic shock (aOR, 1.50; 95% CI, 1.08-2.08; P < .05), acute kidney injury (aOR, 1.25; 95% CI, 1.02-1.54; P < .05), and multiple endoscopies (aOR, 1.57; 95% CI, 1.28-1.93; P < .05) compared with other UGIB patients who required endoscopic therapeutic intervention. UDL was also associated with higher 30-day all-cause (aOR, 1.23; 95% CI, 1.12-1.35; P < .05) and recurrent bleeding-related (aOR, 1.73; 95% CI, 1.45-2.06; P < .05) readmissions. The rate of successful endoscopic treatment was 96.81%.
UDL hemorrhage is an uncommon but highly morbid condition. Current UDL treatment modalities are effective in reducing mortality. Further investigations are warranted to lower recurrent bleeding rates.
A Jejunal Dieulafoy Lesion: Rare Case Necessitating Surgical Intervention
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Dieulafoy lesions are enlarged atypical submucosal vessels that erode the superimposing epithelium in the absence of a primary ulcer. They occur predominantly in the gastric mucosa; however, cases have been seen throughout the gastrointestinal (GI) tract, and rarely, the jejunum. These lesions can cause massive GI hemorrhage leading to shock.
We present a healthy 19-year-old male who arrived at our institution’s emergency department with multiple episodes of hematemesis and hematochezia that began earlier that morning. The patient was resuscitated and underwent a computerized tomographic (CT) angiography that did not identify any areas of active extravasation. The patient was then taken for an emergent upper and lower endoscopy that was inconclusive. He was subsequently sent for a tagged red blood cell scan, which demonstrated active bleeding in the proximal jejunum. Shortly thereafter, the patient began to decompensate requiring additional blood products and vasopressors. The decision was made for immediate operative intervention, which identified the bleeding Dieulafoy lesion (confirmed by histopathology) in the jejunum.
Dieulafoy lesions are rare with an initial presentation of upper or lower GI bleeding, generally treated with endoscopic intervention. They are predominately found in the stomach or duodenum. When no clear source is identified by endoscopy, further diagnostic testing may be of value. Various imaging modalities exist; however, CT angiography or radionuclide scanning are particularly sensitive and can be beneficial in localizing the bleed when preparing for operative intervention.
With advances in endoscopic techniques, surgical intervention is rarely performed for a Dieulafoy lesion. If endoscopy is unsuccessful, additional imaging can be obtained to localize the source of bleeding. However, in emergent cases, when additional imaging cannot be obtained due to lack of time or resources, adequate resection of the lesion should be performed for complete resolution of the disease process. Based on the case presentation and pathologic findings, this case provides further insight into Dieulafoy lesions and the rare need for surgical management.
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Dieulafoy's lesion is an uncommon but important cause of recurrent upper gastrointestinal bleeding. Extragastric location of Dieulafoy's lesion is rare. We report a case of haemorrhagic shock due to delafoy ulcer of the duodenum. After the failure of endoscopic haemostatic treatment, and due to the hemodynamic instability, the patient was not a candidate for transarterial embolization, the emergency surgery was needed to stop the bleeding. Using minimally invasive technique, we were able to avoid radical surgery, in critical patient would have high mortality rate. Aggressive endoscopic examinations combined with the accurate treatment endoscopic, or after the failure of this, in cases of severe hemorrhagic shock, surgical approach should be adopted when Dieulafoy-like lesion is suspected as a possible cause of upper GI haemorrhage.

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^☆: Reprint requests: Il-Kwun Chung, MD, Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Hospital, 23-20 Bongmyung-dong, Chonan city, Choongnam 330-100, Republic of Korea.

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Original ArticlesBleeding Dieulafoy's lesions and the choice of endoscopic method: Comparing the hemostatic efficacy of mechanical and injection methods☆

Abstract

Section snippets

Patients and methods

Clinical characteristics

Discussion

Gastrointest Endosc

Gastrointest Endosc

Hum Pathol

Gastrointest Endosc Clin North Am

Gastrointest Endosc

Exulceration simplex

Bull Acad Med

Original Articles
Bleeding Dieulafoy's lesions and the choice of endoscopic method: Comparing the hemostatic efficacy of mechanical and injection methods☆