Bleeding Dieulafoy Lesion Research Articles

Fatal exulceratio simplex (dieulafoy lesion) – a case report and review

AbstractA 64-year-old man involved in a low-speed vehicle crash was found at autopsy to have altered blood extending from his stomach to his rectum. Within the stomach a small arterial vessel opened onto the mucosa of the posterior wall of the antrum adjacent to the pylorus with no adjacent mucosal ulceration or malignancy. Histologic sections showed the typical appearances of a Dieulafoy lesion with a tortuous small arteriole within the submucosa extending to the gastric lumen with an overlying cap of recently formed clot. There were no injuries attributable to the vehicle collision. Death was due to a bleeding Dieulafoy lesion of the stomach with a background of cardiomegaly. Dieulafoy lesion of the stomach is a rare disorder accounting for only 1–2% of cases of acute gastrointestinal hemorrhage. Although its pathogenesis is poorly understood it is capable of producing life-threatening bleeding, as in the present case. The small size of the lesion may make it difficult to identify at the time of autopsy.

S2666 Three Simultaneous Sources of Upper GI Bleeding

Introduction: Acute upper GI bleeding is one of the most common causes of gastrointestinal related hospitalizations. Presentation of these patients commonly includes melena, hematemesis, or unstable hematochezia. One of the most common etiologies for this presentation is peptic ulcer disease. However less common causes include Dieulafoy lesions and iatrogenic gastric fistulas. The following case discusses three simultaneously diagnosed causes of upper GI bleeding. Case Description/Methods: An 82-year-old male with a history of splenectomy presented with melena and syncope. The day of arrival patient had syncopized after having multiple large bouts of black stool. On presentation, he was hypotensive, and tachycardic. His hemoglobin was 6.3 g/dL with a BUN of 62 mg/dL. An EGD was planned following patient stabilization. Initial EGD revealed a single 8mm ulcer in the duodenal bulb with no stigmata of bleeding. Just distally to the ulcer in the duodenal sweep was an actively bleeding Dieulafoy lesion. Hemostasis was achieved with bipolar cautery and the active bleed was stopped. Retroflexion during the initial procedure showed retained clot and old blood in the fundus that was presumed from the Dieulafoy lesion. Despite intervention, patient continued to have large bouts of melena the evening after the procedure. A 2nd EGD was performed and showed a stable ulcer and no signs of recurrent Dieulafoy. The fundus was now more visible and revealed ischemic damage. Careful inspection revealed a fistula with suture material free floating. Review of the operative note from the splenectomy revealed patient suffered a small laceration to the gastric fundus during the procedure which was repaired with an inner row of sutures. Given the size of the fistula, decision made for a CT scan to better define the anatomy. Unfortunately, the patient continued to decompensate, and family ultimately elected for comfort care. (Figure) Discussion: Dieulafoy lesions and gastric fistulas are both relatively rare, but potentially life-threatening, conditions. A Dieulafoy is a narrow artery that bleeds through a small mucosal defect. Therapeutic endoscopy can control the bleeding in 90% of patients while angiography is being accepted as an alternative to endoscopy for inaccessible lesions. The most common site for a Dieulafoy lesion to appear is in the lesser curvature. Gastric fistulas status post splenectomy occur in less than 1% of cases with the usual site along the greater curvature near the fundus.Figure 1.: Top left: Index EGD showing a single cratered 8mm ulcer in the duodenal cap. Top right: Index EGD with active Dieulafoy bleed in the duodenal sweep, just distal to ulcer. Bottom left: 2nd EGD showing free floating suture material and ischemia in the fundus Bottom right: 2nd EGD showing obvious fistula with ischemic changes, obscured by clot and old blood during index endoscopy.

Massively bleeding Dieulafoy lesion and unique rescue: a video based case report from National Liver Institute, Menoufia University

BackgroundDieulafoy arteriole is a lamina propria vessel that unlike the other arterioles is getting bigger and bending into the mucosa of the gastrointestinal tract. Such anatomic aberration is unusual cause for life threatening gastrointestinal bleeds.Case presentationHerein, we report a case of an elderly gentleman, who had massively bleeding Dieulafoy lesion and endoscopic hemostasis of the spurting Dieulafoy by the use of the over-the-scope clip (OVESCO, Tübingen, Germany) has been successfully undertaken.ConclusionThe endoscopic management of Dieulafoy related bleeds can be enriched by the use of over-the-scope clip, OVESCO, technique.

Longitudinal Gastrectomy for Nonbariatric Indications

Background Sleeve gastrectomy is the most commonly performed bariatric procedure. Laparoscopic longitudinal gastrectomy (LLG) may be indicated for other indications. Patients and Methods. Two men and two women aged 67, 72, 77, and 80 years underwent LLG for nonbariatric indications with two having normal weight, one being cachectic, and one severely obese. Results LLG was discussed with patients prior to surgery, but decision for LLG was made during surgery after contemplating other surgical options. A wide sleeve over a 42 French bougie was created with the staple line being oversewn with running 3–0 silk. Indications included a bleeding Dieulafoy lesion that failed endoscopic clipping, fundus gland polyposis found during paraesophageal hernia repair, fundus nodules suspected to be leiomyosarcoma metastases revealing splenosis on final pathology, and significant gastric dilatation associated with organoaxial gastric volvulus. Three patients had an uneventful recovery; the severely obese patient temporarily lost weight but died after two years from a stroke. The last patient developed dysphagia due to an alpha-loop in the sleeve, which was managed by endoscopic stenting. The device subsequently migrated and was laparoscopically removed, with a side-side gastrogastrostomy performed to straighten the alpha-loop. The patient tolerated food better and with overnight PEG tube feeds gained weight but continued heavy smoking. He died after one year from COPD exacerbation. Conclusion LLG seems to be an appropriate intervention for various gastric pathologies. Training of residents and fellows in the minimally invasive surgical steps of LLG is encouraged.

Dieulafoy lesions as cause of upper gastrointestinal bleeding in a patient with portal hypertension

ABSTRACT Dieulafoy’s lesion is an abnormally large and tortuous submucosal artery that protrudes through a small mucosal defect resulting in gastrointestinal bleeding. We present a case of a 53-year-old man with a history of HIV and alcohol abuse who presented to the emergency room with hematemesis and melena. Upper endoscopy revealed an actively bleeding dieulafoy lesion, but due to uncontrolled bleeding, embolization of the left artery was necessitated. The incidence of dieulafoy lesions is about 0.3% to 6.7% within the stomach. The etiology remains uncertain but has been linked to alcoholism and antiplatelet drugs. We are emphasizing the importance of considering uncommon causes of upper gastrointestinal bleeding in patients with portal hypertension.

S2186 Colonic Dieulafoy's Lesion: A Rare Presentation of Lower GI Bleeding

INTRODUCTION: Dieulafoy's lesions (DL) are rare (1–2%) causes of gastrointestinal bleeding. Colonic DLs are even rarer (∼2%) cause of lower GI bleeding.Early recognition of this entity is important given its infrequent occurrence, and yet, potentially life-threatening outcome. CASE DESCRIPTION/METHODS: A 64-year-old male with HFrEF, CKD and A- Fib on Eliquis 5 mg BID and Aspirin 81 mg presented to ER with 6-week history of melena with a hemoglobin of 7.4 g/dL on admission, BP of 95/55 mmHg, pulse of 65 bpm and an oxygen saturation of 98% on 2 L O2. Abdominal examination was unremarkable. His INR was 1.3. He received 3 units of pRBC. EGD was negative. Colonoscopy performed thereafter revealed fresh blood throughout the entire colon and a pulsatile, non spurting, briskly bleeding artery in mid transverse colon. Successful hemostasis was achieved with 2 clips (Figure 1) and injection of epinephrine (1:10,000). A tattoo was placed near the lesion. He denied ongoing rectal bleeding but continued to have dark solid stools on iron supplements for chronic anemia. Follow-up colonoscopy pursued 4 months later to perform polypectomy showed a similar arterial type bleeding vessel in proximal ascending colon and was completely ablated with Argon Plasma Coagulation at 0.8 L/min flow and 20 max Watts (Figure 2). The patient was sent home on continued iron replacement, and advised to resume Elliquis the next day; and is doing well presently. DISCUSSION: DL is a normal vessel with an abnormally large diameter maintaining a constant width of 1-3 mm as it runs a tortuous course within the submucosa and typically protrudes through a small (2-5mm) mucosal defect with basal fibrinoid necrosis. DLs are mostly found in stomach (71%, 85% on lesser curvature). Colonic DLs account for 2% of cases of lower GI bleeding. Typically, patients are elderly male with cardiopulmonary and renal dysfunction, often are on antiplatelet or anticoagulant agents (AP/AC) and presents with acute, intermittent, and clinically significant melena, hematochezia, or symptoms of shock. Exact pathogenesis of spontaneous rupture is unknown but mucosal ischemia or erosion from ageing, arteriolar pulsation, cardiovascular disease, AP/AC agents and stercoral injury may unmask the silent anomaly. GI endoscopy is preferred in diagnosis and successful management (>90%) of DLs as in our patient while embolization and surgery are reserved for refractory cases.Figure 1.: Colonoscopic view of an actively bleeding Dieulafoy's lesion in transverse colon (left) and subsequent hemostasis with clips and epinephrine (right).Figure 2.: Colonoscopic view of an actively bleeding Dieulafoy's lesion in ascending colon (left) and subsequent hemostasis with argon plasma coagulation(right).

S3458 A Tale of Two Dieulafoy’s: Massive GI Hemorrhage from Synchronous Dieulafoy Lesions

INTRODUCTION: Dieulafoy lesions (DL) are an elusive source of gastrointestinal hemorrhage accounting for 5% of all cases. They consist of large aberrant submucosal arterioles that erode through overlying epithelium. Patients present with hematemesis, melenic stools, and/or hemodynamic instability. Bleeding is from a single lesion in the stomach (64%), small intestine (20%), colon (10%), or esophagus (2%). Diagnosis is difficult in the absence of overt bleeding and repeat endoscopy is often required. Management includes epinephrine injection, thermal ablation, hemoclips, or resection. Unfortunately, recurrence can be seen in 5-10% of cases. We report an exceedingly rare case of two synchronous DL actively bleeding during one hospitalization. CASE DESCRIPTION/METHODS: A 61 year old male with ESRD, CAD status-post bypass grafting, atrial fibrillation, and heart failure status-post mitral valve replacement presented with four weeks of melena. Index endoscopy demonstrated duodenal bulb and cecal angioectasias that were ablated with snare polypectomy of four polyps. Bleeding persisted so capsule endoscopy was pursued showing fresh blood in the jejunum and distal ileum. Upper double balloon-assisted enterography (DBE) showed an actively bleeding DL in the mid-distal jejunum that was treated with APC, hemoclips and marked with India Ink. Melena and transfusion-dependent anemia persisted and repeat upper DBE showed oozing from prior DL ablation, thus retreated with APC. Bleeding continued but IR angiogram was unrevealing, so resection was pursued. Unfortunately, despite resection, video capsule, and two colonoscopies with hemoclip placement at polypectomy sites, bleeding continued. A lower DBE revealed an actively bleeding DL 50cm proximal to the ileocecal valve that was treated with APC and hemoclips. Hemostasis was achieved and the patient was discharged. DISCUSSION: Despite endoscopy and small bowel series, the source is not found in up to 5% of overt GI hemorrhages. While DL account for only 5% of GI bleeding cases, they are important due to their propensity to cause significant hemorrhage. DL are typically solitary; only two cases of synchronous DL have been reported in literature, and were isolated to the stomach or stomach and small bowel. This is an unusual case of persistent GI bleeding caused by two active small bowel DL (distal jejunum and ileum) which were synchronously bleeding during one hospital admission. As far as we know, this is the only reported case of two actively bleeding DL in the small bowel.Figure 1.: Initially identified DL in mid-distal jejunum treated with APC & hemoclips.Figure 2.: Synchronous DL 50cm from ICV.

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

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

Dueling with Fire: A Case Series of Dieulafoyʼs Lesions

Dieulafoy's lesion is a rare cause of gastrointestinal (GI) bleeding that is often misdiagnosed or missed, accounting for 1-5.8% of cases of acute GI bleeding, 1.9% of all endoscopies for acute GI bleeding and 0.09% of all colonoscopies performed for lower GI bleeding. It is thought to affect already hospitalized or otherwise incapacitated patients, thus it is essential to understand the clinical presentation and approach to care. Three female patients aged 56, 64 and 75 presented with melena and symptomatic anemia with hemoglobin levels ranging from 4.7 to 8.4. Two of the patients had coffee ground emesis prior to admission. One patient had a history of taking NSAIDs, two taking daily aspirin and one patient on warfarin for a mechanical valve. All three patients underwent an EGD. All patients had a normal esophagus; the first patient had a bleeding Dieulafoy's lesion in the lesser curvature of the antrum, the second in the greater curvature of the antrum and the third with a lesion in the second portion of the duodenum. Lesions were treated by regional hemostasis with epinephrine injections and thermal hemostasis via heat probe in two of the three cases, and mechanical hemostasis was achieved with haemoclips in two of the three patients. Repeat melena occurred in two patients and was thought to be due to inadequate hemostasis or re-bleeding in the duodenum. All patients were discharged on a PPI. Dieulafoy's lesion is a rare cause of GI bleeding due to histologically normal but tortuous and dilated submucosal vessels. The most common location is in the stomach followed by the duodenum, with duodenal and jejunal lesions making up 15% and 1% of all lesions respectively. Patients present with painless and often massive periodic hematemesis, melena, or hematochezia. Risk factors include a history of NSAIDs, aspirin, or warfarin use. Diagnosis can be made most often by direct visualization via endoscopy. Treatment consists of hemostasis achieved thermally, regionally with local epinephrine injections, and sclerotherapy, or mechanically with banding or haemoclips. Literature suggests that mechanical haemostatis methods are most effective and successful. For those unresponsive to treatment, angiography with embolization has been used. If both fail, surgery is advised if no source can be defined and active bleeding continues. Prognosis has improved significantly in recent years, from 80% mortality down to 8.5%.

Improved Visualization With Cap Fitted Colonoscopy in Lower GI Bleeding

Lower gastrointestinal bleeding is one of the most frequently encountered conditions by gastroenterologists. Locating a treatable source can be difficult due to the time required for bowel preparation and cessation of bleeding, intermittent nature of bleeding, as well as poor visibility in the setting of active bleeding. We present a case illustrating the use of endoscopic cap to improve visualization and aid in treatment of an actively bleeding cecal Dieulafoy lesion. An eighty-two-year-old female with a past medical history of end stage renal disease, coronary artery disease on aspirin, and diabetes mellitus. She presented to the emergency department with fatigue, shortness of breath, pallor, and melena. Initial laboratory results were significant for a hemoglobin of 4.1. The patient was admitted to the hospital and underwent an EGD. The EGD was significant for a 2cm antral erosion, which was not felt to be the source of bleeding to account for the patient's anemia and so colonoscopy was performed. There was a large amount of blood that repeatedly obscured the lens of the colonoscope. Despite continuous attempts to clean the lens intraluminally, the scope was removed twice to clean the lens manually. Prior to the third insertion, an endoscopic cap was placed. The cap improved visibility by preventing blood from adhering to the lens allowing for safe insertion of the colonoscope. Careful inspection of the cecum revealed an actively bleeding Dieulafoy lesion. A single endoscopic clip was placed, achieving hemostasis and the patient was discharged home without further issue. Use of endoscopic caps during lower GI bleeding has not been well studied. Their use has been shown to improve adenoma detection rates (ADR) when cap fitted colonoscopy (CFC) was compared to non-CFC. This benefit was attributed to improved visualization within the colon. Cap fitted EGD has also been shown to improve visualization and ease of access to target lesions. The case described above shows that CFC may be a very useful tool in localizing and treating lower GI bleeding sources through improved visualization and ultimately achieving hemostasis.

A Rare Case of Massive Gastrointestinal Bleeding From a Rectal Dieulafoy Lesion

A Dieulafoy lesion (DL) is defined as a dilated sub-mucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. DL lesions of the rectum are a rare cause of gastrointestinal bleeding that is difficult to identify and subsequently manage. We present an 84-year-old man, who presented with lower gastrointestinal bleeding secondary to a DL of the rectum. An 84-year-old man with a medical history significant for End-stage renal disease(ESRD), and hypertension presented to our emergency department with multiple episodes of rectal bleeding mixed with bowel movements. On physical examination, he was hemodynamically stable, with rectal examination notable for bright red blood on the examining finger. His initial complete blood count showed a hemoglobin of 8.4 g/dL, with other normal indices. The patient was rapidly prepped for colonoscopy. Colonoscopy revealed an actively spurting Dieulafoy lesion in the distal rectum just proximal to the pectinate line associated with underlying friable mucosa. Hemostasis was achieved with injection of 3cc of 1:10000 epinephrine, and application of 3 hemostatic clips. He remained stable, with no subsequent rectal bleeding and was discharged home. DLs first described by Gallard in 1884, is a rare cause of gastrointestinal bleeding.They are believed to account for an estimated 1-2% of all cases of acute GI bleeding and can be associated with high mortality rate. The etiology of Dieulafoy lesions are unknown. Risk factors associated with their development include male gender, hypertension, and ESRD, which were present in our patient. With regards to location, DLs are most commonly encountered in the stomach and the gastroesophageal junction. DLs of the rectum is a rare entity, observed in a mere 2% of reported cases in the literature. Bleeding episodes of DL are usually self-limited, however, they are usually recurrent and can lead to profuse rectal bleeding. Diagnosis of DLs, both gastric and rectal, can often time be challenging for the clinician. Endoscopy is the gold standard for diagnosis, but is only successful in 70% of cases, requiring the need for repeat endoscopy to establish the diagnosis. Treatment of rectal DLs is best accomplished endoscopically using a combination of epinephrine injection with bipolar probe coagulation, hemoclip placement, or thermal coagulation. Rarely angiograph and surgery is indicated in failed endoscopic therapy.1991_A Figure 1. An actively bleeding dieulafoy lesion in the distal rectum, just proximal to the pectinate line.1991_B Figure 2. Hemostasis achieved with 3 hemostatic clips.

The Bends in the Blood Vessels: Dieulafoyʼs Vascular Malformation

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

Endoscopic band ligation versus endoscopic hemoclip placement for Dieulafoy's lesion: a meta-analysis.

Dieulafoy lesions (DL) are abnormally large arterial lesions that fail to decrease in size as they emerge from the submucosa to the mucosal surface. Endoscopic treatment has become the mainstay of therapy for actively bleeding DL lesions. In this meta-analysis, we aim to assess the efficacy of both techniques in achieving primary hemostasis of actively bleeding DL lesions and their rates of rebleeding. Our search included the Pubmed, Scopus and CINAHL electronic databases. The initial search yielded 440 articles and after appropriate review by 2 individual reviewers, 5 studies met inclusion criteria. Review manager version 5.3 was used for statistical analysis. There were 75 patients treated with EBL and 87 patients treated with EHC. The success rate of primary hemostasis of EBL for bleeding DL lesions was 0.96 [95% confidence interval (CI): 0.88-0.99]. The success rate of primary hemostasis of EHC for bleeding DL lesions was 0.91 (95% CI: 0.83-0.96). The recurrence of bleeding for patients treated with EBL was 0.06 (95% CI: 0.02-0.15). The recurrence of bleeding for patients treated with EHC was 0.17 (95% CI: 0.10-0.28). There was no statistical significance in primary hemostasis or rebleeding in patients treated with EBL or EHC. There was no significant heterogeneity between studies included in the analysis. Endoscopic band ligation and endoscopic hemoclip placement are efficacious procedures for the treatment of NVUGIB secondary to DL with similar rates of primary hemostasis and rebleeding.

Jejunal Dieulafoy Lesion Detected by Intraoperative Endoscopy in a Child

Introduction: Dieulafoy lesion is an unusual cause of gastrointestinal bleeding in which significant, and often recurrent, hemorrhage occurs from a pinpoint non-ulcerated arterial lesion. It is usually located in gastric fundus, and is extremely rare in children. Case Presentation: In this study, we present a male adolescent with jejunal Dieulafoy lesion. The patient was admitted to the hospital due to hematochezia and hypotension. No active bleeders were identified on endoscopy, colonoscopy, and double-balloon enteroscopy. Computed tomography angiography revealed active bleeders in jejunum. An intraoperative enteroscopy, using flexible endoscopy, revealed a jejunal Dieulafoy lesion with spurting bleeding. The patient was successfully treated by bowel resection. Conclusions: Intraoperative endoscopy is a relatively efficient and safe modality for evaluating the bleeding Dieulafoy lesion in the small intestine, and is essential for directing surgery.

Endobronchial Nd:YAP Laser Ablation of a Bleeding Dieulafoy Lesion of the Bronchus

Endobronchial Nd:YAP Laser Ablation of a Bleeding Dieulafoy Lesion of the Bronchus

A single-center United States experience with bleeding Dieulafoy lesions of the small bowel: diagnosis and treatment with single-balloon enteroscopy.

Introduction: A Dieulafoy lesion (DL) of the small bowel can cause severe gastrointestinal bleeding, and presents a difficult clinical setting for endoscopists. Limited data exists on the therapeutic yield of treating DLs of the small bowel using single-balloon enteroscopy (SBE). Methods: Data were collected from Tampa General Hospital a 1 018-bed teaching hospital affiliated with University of South Florida in Tampa, Florida. Patients were selected from a database of patients that underwent SBE from January 2010 – August 2013. Results: Eight patients were found to have DL an incidence of 2.6 % of 309 SBE performed for obscure gastrointestinal bleeding. 7/8 were identified in the jejunum, with one found in the duodenum. The mean age of patients with DL was 71.5 years old. 6/8 patients were on some form of anticoagulant/antiplatelet agent. The primary modality of therapy employed was electrocautery, multipolar electrocoagulation in seven patients and APC (argon plasma coagulation) in one patient. In three patients, electrocoagulation was unsuccessful and hemostasis was achieved with clip placement. Three patients required repeat SBE with one found to have rebleeding from a failed clip with hemostasis achieved upon reapplication of one clip. Conclusion: In our United States’ experience, SBE offers a reasonable therapeutic approach to treat DL of the small bowel with low rates of rebleeding, no adverse events, and no patient requiring surgery.

PWE-188 Do proton pump inhibitors prevent upper gastrointestinal bleeding in patients treated for acute coronary syndrome?

Introduction NICE recommends dual anti-platelet therapy (DAPT) for 12 months following an acute coronary syndrome (ACS). 1 DAPT carries a risk of gastrointestinal (GI) bleeding. The incidence and outcome of patients who have a GI bleed whilst taking DAPT are not well known and despite recommendations, the protective effects of proton pump inhibitors (PPIs) in this group are debated. 2 We studied readmission rates with UGI bleeding and subsequent outcomes in ACS patients for one year following their event. We analysed data to ascertain whether there was any benefit to co-prescription of PPI with DAPT. Method Data were collected using the Northumbria Myocardial Infarction National Audit Project (MINAP) database, for the calander year 2012. We analysed 12 month readmission rates with GI bleeding and subsequent outcomes; including endoscopic findings, the use of PPI, mortality data and age demographics. Results 585 patients suffered an ACS in our study population. 12 patients (2%) were readmitted with GI bleeding within the first year. Nine patients were male, with a median age of 82 years, and three were female: median age 90 years. Lansoprazole (a PPI) 30mg daily was prescribed for 8/12 (66%) patients. Seven patients (58%) died; two directly as a consequence of GI bleeding and five due to subsequent complications. In those taking a PPI the mortality rate was 50% (4/8). In the non-PPI group the mortality rate was higher at 75% (3/4). Regarding UGI endoscopy; four patients did not undergo intervention on clinical grounds. In those who underwent upper GI endoscopy, diagnoses included: oesophagitis, gastritis, duodenal ulceration, gastric ulceration, oesophageal ulceration and possible bleeding Dieulafoy lesion. In two patients, no cause for bleeding was found. Considering those aged 80 or older; 227 patients suffered an ACS. Nine of these were readmitted with GI bleeding (4%) with only two patients surviving that admission (mortality rate 78%). In the 358 patients under the age of 80, the risk of re-admission with GI bleed was 0.8% and the mortality rate was zero. Conclusion The risk of readmission with GI bleeding in the first year following ACS whilst on DAPT is low (2%). The protective effects of PPIs in GI bleeding in patients taking DAPT have not been demonstrated by this study. However, we note a higher mortality rate in the non-PPI group. Patients over 80 years old have a poor outcome and higher mortality rate despite prescription of PPI. Treatment decisions for this specific group should be carefully considered. Disclosure of interest None Declared. References NICE. Antiplatelet treatment:secondary prevention of CVD http://cks.nice.org.uk/antiplatelet-treatment Moukarbel GV, et al . Gastrointestinal bleeding in high risk survivors of myocardial infarction. Eur Heart J. 2009;30:2226–2232

15 Incidence and Outcome from Upper GI Haemorrhage in the First Year following an Acute Coronary Syndrome

<h3>Introduction</h3> NICE recommends dual anti-platelet therapy (DAPT) for 12 months following an acute coronary syndrome (ACS). DAPT carries a risk of significant bleeding particularly from the GI tract. The incidence and outcome of patients who have a GI bleed whilst taking DAPT is not well known and despite the recommendations, the protective effects of proton pump inhibitors (PPI) in ACS patients receiving DAPT are debated and robust evidence is lacking. We studied readmission rates with UGI bleeding and subsequent outcomes in ACS patients for the first year following their event. We recorded the incidence and outcome to ascertain whether there was any benefit to co-prescription of PPI with DAPT. <h3>Results</h3> 585 patients suffered an ACS during the calendar year 2012; recorded on the Northumbria NHS trust MINAP database. 12 patients (2%) were found to have been readmitted to the same trust with a diagnosis of GI haemorrhage within that 12 month period. Nine patients were male with a median age of 82 years; 3 were female, with a higher median age of 90 years. Lansoprazole (a PPI) 30 mg daily was prescribed for 8 out of 12 (66%) patients. Four patients were not prescribed a PPI. Seven patients (58%) died (mean age 85). Two patients died as a direct result of their GI haemorrhage and 5 died due to subsequent complications. In those taking a PPI the mortality rate was 50% (4 of 8 patients) and in those not taking a PPI the mortality rate was higher at 75% (3 out of 4 patients). Regarding UGI endoscopy; four patients did not undergo intervention as it was deemed inappropriate on clinical grounds. In those who underwent UGI endoscopy, diagnoses included: oesophagitis, gastritis, duodenal ulceration, gastric ulceration, oesophageal ulceration and a possible bleeding Dieulafoy lesion. In two patients, no cause for the bleeding was found. <h3>Conclusions</h3> The risk of readmission with upper GI haemorrhage in the first year following an ACS whilst on DAPT is low (2%). However, patients who are admitted are elderly and frail and have a poor outcome despite the prescription of PPI therapy. Shortening the duration of DAPT therapy in the elderly, particularly if medically treated should be considered.

Dieulofaloy lezyonunun kombine tedavisi: Olgu sunumu

Dieulafoy's lesion is an uncommon, but important, cause of upper gastrointestinal bleeding. Dieulafoy's lesion is usually seen in the stomach, but sometimes can be seen in the small or large bowel. Typically, it is located within 6 cm of the esophagogastric junction, generally along the lesser curvature of the stomach. Various methods with endoscopy are used to control the hemostasis due to these lesions, but the most suitable endoscopic treatment method for treating bleeding Dieulafoy's lesion is not yet well established. Argon plasma coagulation has been used successfully in upper gastrointestinal bleeding; however, the experience using argon plasma coagulation to treat Dieulafoy's lesion is quite limited. Herein, we report a case with a bleeding gastric Dieulafoy's lesion that was treated using a combined endoscopic approach with injection therapy and argon plasma coagulation

Outcomes in Dieulafoy's Lesion: A 10-Year Clinical Review.

Dieulafoy's lesion (DL) is a rare, but serious cause of gastrointestinal bleeding, most frequently treated with endoscopic therapy. We examined 10 years of data to assess clinical outcomes in DL. Data were captured by retrospective chart review to assess 109 patients treated endoscopically for bleeding DL from 2003 to 2013. Data collected included demographics, comorbidities, presenting symptoms, risk factors, laboratory values, treatment, rebleeding, surgical intervention, and mortality. Treatment success, rebleeding rates, and mortality were the main outcomes measured. Of 109 patients with bleeding DL, 54 % were male and 46 % were female. Mean age was 79.4 years; mean follow-up duration was 40.4 ± 35.8 months. Clinical presentation for most patients included melena, hematemesis, hematochezia, and/or anemia with approximately one-third of patients also experiencing anemia-related symptoms. Most lesions were located in stomach (53 %) followed by duodenum/jejunum (33 %) and large intestine (13 %). Thermal endoscopic therapy (70 %) was the most frequently performed procedure followed by injection (46 %) and mechanical (46 %) endoscopy therapy at equal frequency. Combined therapy (51 %) was common, with over half of patients undergoing two or more endoscopic modalities simultaneously. The finding that only 11 (10 %) patients had rebleeding from DL suggests that endoscopic therapy resulted in successful hemostasis in the remaining 98 patients (90 %) during follow-up. Mortality related to DL was low. Most patients with bleeding DL presented with symptoms of acute bleeding, but many had symptoms suggesting subacute or chronic bleeding. Endoscopic therapy resulted in successful hemostasis in approximately 90 % of patients during follow-up. Rebleeding was rare and particularly uncommon in those treated with combined endoscopic therapy.