EUS-aided diagnosis and treatment of bleeding gastric Dieulafoy's lesion (with video).

Abstract

Dieulafoy's lesion is an uncommon life-threatening condition, accounting for 1.5% of upper gastrointestinal (GI) bleeding.[1] This is due to tortuous arterioles (1–3 mm) seen in the submucosal layer,[2] also known as “persistent caliber arteries.” Usually, arteries narrow as they branch out toward the mucosa, and submucosal end arteries are normally 0.12–0.2 mm in diameter.[1] A 64-year-old diabetic and hypertensive male patient was being treated for chronic liver disease with portal hypertension. He underwent a transarterial chemoembolization procedure for hepatocellular carcinoma 2 years ago. He had a history of variceal band ligation. He was referred from a nearby general hospital where he presented with three episodes of hematemesis in the past 6 months. Endoscopy showed a vascular malformation (0.5 cm × 0.5 cm) with central ulcer in the fundus, with a small fundal vessel nearby [Figure 1a]. EUS showed a persistent caliber feeding arteriole with a diameter of 1.7 mm, suggestive of Dieulafoy's lesion, with a prominent vein nearby [Figure 2a]. Endoscopic hemoclipping was attempted, but hemostasis could not be attained because of the difficult position of the lesion. An Ovesco clip (OTSC®, Ovesco Endoscopy AG, Germany), which facilitates effective full circumferential tissue closure, including the vascular malformation, was used. Following deployment of the Ovesco clip, the Dieulafoy's lesion oozing was controlled, but there was separate new oozing from the vein nearby, which was possibly caused by one of the prongs of the Ovesco clip injuring the fundal vein. This was managed by injection of 0.5 ml of cyanoacrylate glue. Endoscopy repeated the following day showed the clip in situ with no active ooze [Figure 1b]. EUS after the procedure showed the clip at the Dieulafoy's lesion impeding flow in the artery [Figure 2b and Video 1]. The patient was under our follow-up for nearly 1 year without further episodes of GI bleeding. In our patient, the Ovesco clip was efficient in achieving hemostasis, as its design aids complete circumferential tissue closure including the vessel involved. There are few case reports for Ovesco clip use in Dieulafoy's in the stomach or duodenum.[34] Angiographic embolization and surgical interventions are reserved for cases when endoscopic interventions fail.Figure 1: (a) Endoscopic picture showing 5x5 mm sized vascular malformation with a small central ulcer (yellow arrow) with a small fundal vessel (white arrow) nearby. (b) Endoscopic picture showing Dieulafoy's lesion after OVESCO clipping (yellow arrow)Figure 2: (a) EUS showing a 1.7 mm sized persistent caliber artery in submucosa (pink arrow) with arterial Doppler pattern. (b) EUS showing OVESCO clip in situ (pink arrow) with abrupt cut off of the arteriole. Doppler suggests arterial patternDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.