Dieulafoyʼs Lesion in the Esophagus: A Rare Cause of Upper Gastrointestinal Bleed

Abstract

Dieulafoy's lesions account for about 1.5% of acute upper gastrointestinal (GI) bleeding and have a propensity to cause massive hemorrhage with a high mortality rate of about 80%. A Dieulafoy's lesion is a dilated, aberrant, submucosal artery eroding the overlying mucosa with no underlying ulcer, aneurysm, or intrinsic mural abnormality. The lesion is most commonly located in lesser curvature of the stomach, with rare occurrences in the esophagus. There have been about 280 published case reports in literature, but only 2 of these reports describe Dieulafoy's lesions in the esophagus. A 55-year-old male presented to the emergency department with a three-day history of melena and a near-syncopal episode. Upon presentation, he had a large amount of hematemesis followed by a syncopal episode. The patient required two units of packed red blood cells (PRBC) and aggressive intravenous fluid resuscitation. He was subsequently transferred to the intensive care unit (ICU) for close monitoring. Emergent endoscopy was performed at the bedside which revealed a visible submucosal vessel in distal esophagus suggestive of a Dieulafoy's lesion. It was sclerosed using an injection of epinephrine and complete obliteration of the vessel was achieved using gold probe cautery. Patient's symptoms of GI bleeding resolved and was discharged home. He was recommended to follow up outpatient for subsequent endoscopy in 8 weeks. Dieulafoy's lesions were first reported by Gallard in 1884, and were more precisely reviewed by Georges Dieulafoy. These lesions are commonly called caliber-persistent arteries. They are most commonly found in the stomach (prevalence 75-90%), but are exceedingly rare in the esophagus (prevalence 8%). Patients most commonly present with hematemesis and melena. Endoscopy has become the mainstay of diagnosis and treatment. The endoscopist may choose to use clipping, thermocoagulation, or to inject epinephrine into the lesion like in our case. Endoscopy has a 70% sensitivity, and if it fails to diagnose the lesion, angiography may be employed and the lesion may be embolized. If minimally invasive approaches fail, surgery is reserved as a last resort. Although Dieulafoy's lesions are exceedingly rare in the esophagus, the high mortality associated with it goes undiscovered and its amenability to life-saving endoscopic therapy prompts us to keep this as a possible differential diagnosis for an upper GI bleed.