The Bends in the Blood Vessels: Dieulafoyʼs Vascular Malformation

Abstract

Dieulafoy's lesion (DL) also known as the caliber-persistent artery of the stomach, cirsoid aneurysm and submucosal arterial malformation, is a developmental malformation in the gastrointestinal (GI) tract characterized by a large submucosal tortuous artery. Here we present a case of Dieulafoy's lesion with massive hematemesis and despite aggressive resuscitative efforts, the patient could not be revived. A 76-year-old hypertensive male presented with an episode of syncope and bright red emesis. After admission, he had two more episodes of massive hematemesis. His vital signs quickly deteriorated with HR- 98/min, BP- 71/35 mm Hg. On examination, there was blood in the mouth, no epigastric tenderness. Labs revealed Hb- decreased from 12.7 to 8.5 gm/dl. Four endoclips were placed during an emergent esophagogastroduodenoscopy (EGD) which showed a non-bleeding DL. He was managed with normal saline, pantoprazole and two units of packed red blood cells (PRBC). He was stabilized and discharged after four days. He was admitted again a week later with massive volume hematemesis. His hemoglobin was 6.0 gm/dl, and he became hypotensive and was started on normal saline and norepinephrine. An emergent EGD was done which showed a large clot and blood in the stomach, endoclips could not be visualized and a 2 mm DL in the proximal body. 600 mL of blood was suctioned, 4 ml of epinephrine was injected, and the lesion was cauterized. Massive transfusion resuscitation protocol was initiated with nine units of fresh frozen plasma (FFP), nine units of PRBC, two units of platelets. Despite all the measures, he continued having multiple episodes of hematemesis An emergent celiac arteriogram for embolization of a bleeding branch of the left gastric artery was done, during which he had a cardiac arrest, and could not be successfully resuscitated. The management of acutely bleeding DLs can be challenging needing early detection, aggressive treatment and close follow up. Clinicians should be cautious and aware of rebleeding risks due to significant mortality. There are no clear guidelines for monitoring of post-endoclip interventions for DLs.2988_A Figure 1. Initial EGD2988_B Figure 2. EGD 1 Week Later2988_C Figure 3. Emergent IR Embolization