Trident Technique of Hemo-Clipping to Successfully Control Bleeding Dieulafoy Lesions: A Case Series

Abstract

Dieulafoy's lesion(s) has shown to be a cause of upper and lower gastrointestinal (GI) bleeding, presenting itself as an engorged submucosal artery eroding through overlying GI mucosa. Although common in the lesser curvature of the stomach, Dieulafoy's lesions have been reported in literature to manifest in the esophagus, duodenum, jejunum, rectum, and even within diverticula. This report discusses 5 cases of bleeding Dieulafoy's lesions located in the GI tract in which hemostasis was achieved utilizing perileional triple hemoclip placement in a “trident” fashion. Patient A(Image 1) was found to have severe anemia warranting blood transfusion. Upper endoscopic evaluation revealed a Dieulafoy's lesion in the fundus of the stomach which was hemoclipped in a “trident” fashion to achieve hemostasis. Patient B through upper endoscopic evaluation revealed a Dieulafoy's lesion in the body of the stomach which was hemoclipped in the “trident” fashion to achieve hemostasis. Patient C underwent a panendoscopy revealing normal upper exam, mild inflammation of the terminal ileum & first degree hemorrhoids. Capsule endoscopy, performed the next day, revealed actively bleeding Dieulafoy's lesion in the duodenal bulb for which a subsequent repeat upper endoscopy was done with hemoclipping of the lesion in a “trident” fashion. Patient D(Image 3) had an emergent endoscopy which revealed an actively bleeding Dieulafoy's lesion within the duodenal bulb. This was controlled via hemoclip placement and Epinephrine injection into the lesion achieving temporary hemostasis. The patient then underwent a gastroepiploic & gastroduodenal embolization procedure with interventional radiology, later proving unsuccessful due to a rebleed. Patient E(Image 2) presented with rectal bleeding. Colon examination showed a Dieulafoy's lesion in the posterolateral rectum 1 cm from the anal verge. Hemoclips were placed in the “trident” fashion, Epinephrine was administered into the lesion, and sclerotherapy was performed to achieve hemostasis. Due to rarity of Dieulafoy's lesions within the General population, randomized controlled trials studying the treatment of Dieulafoy's lesions prove to be difficult. Furthermore, it is important to emphasize that utilization of the triple clip “trident” therapeutic approach, has obtained a high percentage of successful endoscopic hemostasis in Dieulafoy's lesions.1952_A Figure 1. Triple(trident) Clip application and hemostasis of fundic dieulafoy1952_B Figure 2. hemostatis of rectal diulafoy with trident(triple) clip application