Gastrointestinal: Acute haemorrhage from a Dieulafoy lesion within a gastric diverticulum managed endoscopically

Abstract

A gastric diverticulum is an outpouching of the gastric wall. Gastric diverticula are usually asymptomatic and are uncommon anatomic abnormalities at endoscopy. Here we describe the previously unreported occurrence of a bleeding Dieulafoy-type lesion within a gastric diverticulum, managed successfully with conventional endoscopic therapy without requiring surgery. A 75 year old woman presented with a two day history of dyspnoea, light-headedness and melaena. She denied haematemesis or prior gastrointestinal symptoms. She took Aspirin 100 mg daily but otherwise her medical history was unremarkable. At admission, she was initially hypotensive, and was resuscitated with fluids and blood transfusion. Urgent upper endoscopy at her local hospital revealed a gastric diverticulum with overlying clots, but no active bleeding. The patient was subsequently transferred to a tertiary centre (Royal Adelaide Hospital). The patient arrived haemodynamically stable but her haemoglobin was 53 g/l (normal range 115–155 g/l) and thus was transfused four more units. Repeat upper endoscopy showed a 2.5 cm diameter gastric diverticulum in the fundus containing a large clot. Following irrigation, a Dieulafoy-type lesion was seen within the diverticulum (Figure 1). Two hemoclips were deployed across this lesion with no immediate sequelae. Thermocoagulation was avoided due to risk of perforation. A follow-up endoscopy was performed the next day. No blood or clots were apparent. Hemoclips had remained in situ (Figure 2). However subsequently, the patient had a large haematemesis and endoscopy was repeated. The gastric diverticulum had resumed actively bleeding. Dilute (1:1000) adrenaline was injected into and surrounding the diverticulum and haemostasis was again achieved. Surgical review was requested, however no further interventions were required. There was no recurrence of bleeding after 6 months of follow up. The prevalence of gastric diverticula is reported to be 0.02– 0.04% in autopsy and radiological studies, and 0.2% in upper GI endoscopic procedures. Gastric diverticula are usually located posteriorly in the proximal stomach adjacent to the gastro-esophageal junction and exhibit similar features to intestinal diverticula. They are usually discovered incidentally on routine endoscopic or radiographic examination. Most gastric diverticula are asymptomatic but may present with a vague sensation of fullness or discomfort in the upper abdomen. Other complications of gastric diverticula include acute upper GI bleeding which is the most common, with potentially life threatening consequences as in this case. Endoscopic therapy has been previously reported for diagnosis and in one previous case, management of acute bleeding from gastric diverticula, but according to multiple case reports, surgical intervention (laparoscopic approach preferred) is needed in most cases to achieve durable haemostasis.