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An Actively Bleeding Dieulafoy's Lesion

2008; Elsevier BV; Volume: 7; Issue: 5 Linguagem: Inglês

10.1016/j.cgh.2008.10.017

1542-7714

Kevin C. Ruff, Tisha Lunsford, Georges Decker,

Gastrointestinal Bleeding Diagnosis and Treatment

A 73-year-old woman was transferred to our institution for evaluation and treatment of symptomatic, obscure/overt gastrointestinal bleeding. Over the prior month, she had experienced daily loose bowel movements ranging in appearance from melena to bright red blood. Extensive evaluation before transfer included 3 esophagogastroduodenoscopies that revealed only superficial antral erosions. A colonoscopy was remarkable only for left-sided nonbleeding diverticula and internal hemorrhoids. A nuclear medicine gastrointestinal bleed scan and mesenteric angiogram were completed with no evidence of active bleeding. A video capsule endoscopic examination was positive for large amounts of fresh blood in the stomach, duodenum, and proximal jejunum. Repeat video capsule endoscopy revealed no obvious lesions. She required 20 units of packed red blood cells through the course of this evaluation.Physical examination at the time of transfer was positive for maroon-colored stools. A repeat nuclear medicine gastrointestinal bleed scan was negative for bleeding. Computerized tomography angiogram did not reveal any vascular abnormalities. An esophagogastroduodenoscopy showed a small amount of blood oozing from the gastric fundus. No ulceration was noted. Initial treatment using a bipolar probe (Gold Probe; Boston Scientific, Natick, MA) resulted in the sudden appearance of a pulsatile stream of blood (Video 1), suggestive of a Dieulafoy's lesion. Bleeding was controlled temporarily with the placement of 2 endoclips (Resolution endoclip; Boston Scientific) and injection of epinephrine. A subsequent worsening stream of blood required the deployment of 4 additional endoclips to achieve hemostasis. The patient was discharged from the hospital 3 days later with no further bleeding episodes. Recent conversation with the patient 4 months after endoscopic treatment confirmed that she had no further episodes of hematochezia or melena and has required no additional blood transfusions.DiscussionDieulafoy's lesion was first described in 1884 by Gallard.1Gallard T. Aneurysmes miliares de l'estomac dormant lieu a des hematemese mortelles.Bull soc med de hop Paris. 1884; 1: 84-91Google Scholar Dieulafoy himself subsequently described 3 similar cases in 1898 that he called exulceratio simplex.2Dieulafoy G. Exulceratio simplex Clin med de l' Hotel-Dieu de Paris 1897/98, II; l'intervention chirurgicale dans les hematemeses foudroyantes consecutives a l'exulceration simple de l'restomac [French].Presse Med. 1898; : 29-44Google Scholar These lesions, also called caliber-persistent arteries of the stomach or cirsoid aneurysms, are believed to be large-caliber arteries in the submucosa or mucosa with an overlying mucosal defect. The incidence of Dieulafoy's lesion in patients presenting with upper-gastrointestinal bleeding ranges from 0.13% to 2.1%. The average age of patients diagnosed is 46.3 to 67 years old; 50% to 79% of patients are male.3Lee Y.T. Walmsley R.S. Leong R.W. et al.Dieulafoy's lesion.Gastrointest Endosc. 2003; 58: 236-243Abstract Full Text PDF PubMed Scopus (142) Google Scholar Dieulafoy's lesions can occur throughout the aerodigestive tract but the majority is found in the proximal stomach.There are multiple options for treatment with no true gold standard of care. Surgery was the treatment of choice for many years. Bipolar cautery with sclerotherapy and also Nd:YAG laser treatments were first described in the English literature in 1987. Brown et al4Brown G.R. Harford W.V. Jones W.F. Endoscopic band ligation of an actively bleeding Dieulafoy lesion.Gastrointest Endosc. 1994; 40: 501-503Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar described endoscopic band ligation as a treatment option in 1994. The use of endoclips for treatment of Dieulafoy's lesion was reported in 1997 by Parra-Blanco et al.5Parra-Blanco A. Takahashi H. Méndez Jerez P.V. et al.Endoscopic management of Dieulafoy lesions of the stomach: a case study of 26 patients.Endoscopy. 1997; 29: 834-839Crossref PubMed Scopus (97) Google Scholar Most recently, the use of argon plasma coagulation was reported in 2003. Hemostasis rates range from as low as 75% using injection therapy alone to 100% in series using a variety of methods including cautery, endoscopic band ligation, and endoclips.6Park C.H. Joo Y.E. Kim H.S. et al.A prospective, randomized trial of endoscopic band ligation versus endoscopic hemoclip placement for bleeding gastric Dieulafoy's lesions.Endoscopy. 2004; 36: 677-681Crossref PubMed Scopus (81) Google Scholar Rebleeding rates are reported as low as 0% by using endoscopic band ligation, and up to 33% by using injection therapy alone.This case highlights the difficulties in identifying a Dieulafoy lesion and the multiple endoscopic treatment modalities that may be required to achieve hemostasis. A 73-year-old woman was transferred to our institution for evaluation and treatment of symptomatic, obscure/overt gastrointestinal bleeding. Over the prior month, she had experienced daily loose bowel movements ranging in appearance from melena to bright red blood. Extensive evaluation before transfer included 3 esophagogastroduodenoscopies that revealed only superficial antral erosions. A colonoscopy was remarkable only for left-sided nonbleeding diverticula and internal hemorrhoids. A nuclear medicine gastrointestinal bleed scan and mesenteric angiogram were completed with no evidence of active bleeding. A video capsule endoscopic examination was positive for large amounts of fresh blood in the stomach, duodenum, and proximal jejunum. Repeat video capsule endoscopy revealed no obvious lesions. She required 20 units of packed red blood cells through the course of this evaluation. Physical examination at the time of transfer was positive for maroon-colored stools. A repeat nuclear medicine gastrointestinal bleed scan was negative for bleeding. Computerized tomography angiogram did not reveal any vascular abnormalities. An esophagogastroduodenoscopy showed a small amount of blood oozing from the gastric fundus. No ulceration was noted. Initial treatment using a bipolar probe (Gold Probe; Boston Scientific, Natick, MA) resulted in the sudden appearance of a pulsatile stream of blood (Video 1), suggestive of a Dieulafoy's lesion. Bleeding was controlled temporarily with the placement of 2 endoclips (Resolution endoclip; Boston Scientific) and injection of epinephrine. A subsequent worsening stream of blood required the deployment of 4 additional endoclips to achieve hemostasis. The patient was discharged from the hospital 3 days later with no further bleeding episodes. Recent conversation with the patient 4 months after endoscopic treatment confirmed that she had no further episodes of hematochezia or melena and has required no additional blood transfusions. DiscussionDieulafoy's lesion was first described in 1884 by Gallard.1Gallard T. Aneurysmes miliares de l'estomac dormant lieu a des hematemese mortelles.Bull soc med de hop Paris. 1884; 1: 84-91Google Scholar Dieulafoy himself subsequently described 3 similar cases in 1898 that he called exulceratio simplex.2Dieulafoy G. Exulceratio simplex Clin med de l' Hotel-Dieu de Paris 1897/98, II; l'intervention chirurgicale dans les hematemeses foudroyantes consecutives a l'exulceration simple de l'restomac [French].Presse Med. 1898; : 29-44Google Scholar These lesions, also called caliber-persistent arteries of the stomach or cirsoid aneurysms, are believed to be large-caliber arteries in the submucosa or mucosa with an overlying mucosal defect. The incidence of Dieulafoy's lesion in patients presenting with upper-gastrointestinal bleeding ranges from 0.13% to 2.1%. The average age of patients diagnosed is 46.3 to 67 years old; 50% to 79% of patients are male.3Lee Y.T. Walmsley R.S. Leong R.W. et al.Dieulafoy's lesion.Gastrointest Endosc. 2003; 58: 236-243Abstract Full Text PDF PubMed Scopus (142) Google Scholar Dieulafoy's lesions can occur throughout the aerodigestive tract but the majority is found in the proximal stomach.There are multiple options for treatment with no true gold standard of care. Surgery was the treatment of choice for many years. Bipolar cautery with sclerotherapy and also Nd:YAG laser treatments were first described in the English literature in 1987. Brown et al4Brown G.R. Harford W.V. Jones W.F. Endoscopic band ligation of an actively bleeding Dieulafoy lesion.Gastrointest Endosc. 1994; 40: 501-503Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar described endoscopic band ligation as a treatment option in 1994. The use of endoclips for treatment of Dieulafoy's lesion was reported in 1997 by Parra-Blanco et al.5Parra-Blanco A. Takahashi H. Méndez Jerez P.V. et al.Endoscopic management of Dieulafoy lesions of the stomach: a case study of 26 patients.Endoscopy. 1997; 29: 834-839Crossref PubMed Scopus (97) Google Scholar Most recently, the use of argon plasma coagulation was reported in 2003. Hemostasis rates range from as low as 75% using injection therapy alone to 100% in series using a variety of methods including cautery, endoscopic band ligation, and endoclips.6Park C.H. Joo Y.E. Kim H.S. et al.A prospective, randomized trial of endoscopic band ligation versus endoscopic hemoclip placement for bleeding gastric Dieulafoy's lesions.Endoscopy. 2004; 36: 677-681Crossref PubMed Scopus (81) Google Scholar Rebleeding rates are reported as low as 0% by using endoscopic band ligation, and up to 33% by using injection therapy alone.This case highlights the difficulties in identifying a Dieulafoy lesion and the multiple endoscopic treatment modalities that may be required to achieve hemostasis. Dieulafoy's lesion was first described in 1884 by Gallard.1Gallard T. Aneurysmes miliares de l'estomac dormant lieu a des hematemese mortelles.Bull soc med de hop Paris. 1884; 1: 84-91Google Scholar Dieulafoy himself subsequently described 3 similar cases in 1898 that he called exulceratio simplex.2Dieulafoy G. Exulceratio simplex Clin med de l' Hotel-Dieu de Paris 1897/98, II; l'intervention chirurgicale dans les hematemeses foudroyantes consecutives a l'exulceration simple de l'restomac [French].Presse Med. 1898; : 29-44Google Scholar These lesions, also called caliber-persistent arteries of the stomach or cirsoid aneurysms, are believed to be large-caliber arteries in the submucosa or mucosa with an overlying mucosal defect. The incidence of Dieulafoy's lesion in patients presenting with upper-gastrointestinal bleeding ranges from 0.13% to 2.1%. The average age of patients diagnosed is 46.3 to 67 years old; 50% to 79% of patients are male.3Lee Y.T. Walmsley R.S. Leong R.W. et al.Dieulafoy's lesion.Gastrointest Endosc. 2003; 58: 236-243Abstract Full Text PDF PubMed Scopus (142) Google Scholar Dieulafoy's lesions can occur throughout the aerodigestive tract but the majority is found in the proximal stomach. There are multiple options for treatment with no true gold standard of care. Surgery was the treatment of choice for many years. Bipolar cautery with sclerotherapy and also Nd:YAG laser treatments were first described in the English literature in 1987. Brown et al4Brown G.R. Harford W.V. Jones W.F. Endoscopic band ligation of an actively bleeding Dieulafoy lesion.Gastrointest Endosc. 1994; 40: 501-503Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar described endoscopic band ligation as a treatment option in 1994. The use of endoclips for treatment of Dieulafoy's lesion was reported in 1997 by Parra-Blanco et al.5Parra-Blanco A. Takahashi H. Méndez Jerez P.V. et al.Endoscopic management of Dieulafoy lesions of the stomach: a case study of 26 patients.Endoscopy. 1997; 29: 834-839Crossref PubMed Scopus (97) Google Scholar Most recently, the use of argon plasma coagulation was reported in 2003. Hemostasis rates range from as low as 75% using injection therapy alone to 100% in series using a variety of methods including cautery, endoscopic band ligation, and endoclips.6Park C.H. Joo Y.E. Kim H.S. et al.A prospective, randomized trial of endoscopic band ligation versus endoscopic hemoclip placement for bleeding gastric Dieulafoy's lesions.Endoscopy. 2004; 36: 677-681Crossref PubMed Scopus (81) Google Scholar Rebleeding rates are reported as low as 0% by using endoscopic band ligation, and up to 33% by using injection therapy alone. This case highlights the difficulties in identifying a Dieulafoy lesion and the multiple endoscopic treatment modalities that may be required to achieve hemostasis. 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