Esophageal Dieulafoy Lesion: Rare Cause of Massive Upper GI Bleeding

Abstract

Purpose: Introduction The Dieulafoy lesion is tortuous large caliber arteriole protruding through small mucosal defect. It is uncommon cause of upper GI bleeding and accounts for about 2% of cases of bleeding from upper GI tract. Esophageal Dieulafoy lesion is extremely uncommon and less than 10 cases have been reported so far. We report a case of massive upper GI bleeding related to esophageal Dieulafoy lesion that was successfully managed by epinephrine injection and placement of hemoclips. Case Presentation 37 year old Hispanic man with history of alcohol abuse and gastroesophageal reflux disease presented to the emergency room with sudden onset hematemesis. He was actively vomiting a large amount of fresh blood and was intubated for airway protection. There was no prior history of NSAIDs use. He underwent esophagogastroduodenoscopy (EGD) with the finding of a small actively bleeding lesion with fresh adherent clot in the lower esophagus. A total of 4 cc of epinephrine (1 mg, 1:10,000) was injected around the lesion and the clot was suctioned. After removal of clot and irrigation, it was noted that there was a very small mucosal defect with prominent visible vessel in the center with active oozing of blood. At this point two hemoclips were applied over this Dieulafoy lesion with cessation of bleeding. The EGD was otherwise normal. Patient was observed in the intensive care unit over next 24 hours and eventually discharged within 72 hours. Discussion Dieulafoy lesions can cause massive, recurrent and sometimes life threatening gastrointestinal bleeding. In the upper gastrointestinal tract, the clinical presentation is hematemesis with or without aspiration pneumonia and melena. About 75-95% of the Dieulafoy lesions are found in the stomach, predominantly along the lesser curvature. However, Dielafoy lesions are also reported in the esophagus, small intestine and colon. Esophageal Dieulafoy lesions are extremely rare. With advances in the endoscopic technique over the years, endoscopic therapeutic interventions for bleeding Dieulefoy lesions are preferred over surgery as the initial management. Epinephrine injection with or without application of band ligation or hemoclip application are described in the literature as therapeutic options. In the only published randomized control trial comparing epinephrine injection alone versus band ligation, lower rebleeding rates were observed with band ligation. However, therapeutic efficacy of hemoclips has not been compared with band ligation due to the rare nature of the disease.