Bleeding Dieulafoy Lesion Research Articles

A Single-Center U.S. Experience with Bleeding Dieulafoy Lesions of the Small Bowel: Diagnosis and Treatment with Single-Balloon Enteroscopy

A Single-Center U.S. Experience with Bleeding Dieulafoy Lesions of the Small Bowel: Diagnosis and Treatment with Single-Balloon Enteroscopy

Bleeding Dieulafoy's Lesion of the Duodenum as Treated by Endoscopic Metal Clip Placement

Dieulafoy's lesion (DL) is a rare source of gastrointestinal tract bleeding that may occur at any site in the gastrointestinal tract and may be difficult to detect by endoscopy. DL is characterized by a large, tortuous arteriole in the submucosa. This is a case of duodenal DL that is detected and treated by endoscopy. This article is part of an expert video encyclopedia.

Su1917 Comparison of Clinical Outcomes of Bleeding Dieulafoy's Lesions and Peptic Ulcers With Stigmata of Recent Hemorrhage

Su1917 Comparison of Clinical Outcomes of Bleeding Dieulafoy's Lesions and Peptic Ulcers With Stigmata of Recent Hemorrhage

Delayed perforation 10 days after endoscopic hemostasis using hemostatic forceps for a bleeding Dieulafoy lesion

Delayed perforation 10 days after endoscopic hemostasis using hemostatic forceps for a bleeding Dieulafoy lesion

Embolization of a bleeding Dieulafoy lesion of the duodenum in a child. Case report and review of the literature

We report an adolescent with chronic, recurrent upper gastrointestinal bleeding in whom extensive prior investigations failed to reveal the source of bleeding. Angiography accurately identified a bleeding Dieulafoy lesion of the duodenum which was successfully embolized. The clinical history, angiographic appearances and treatment of this rare lesion are presented.

Arterial embolization of a bleeding gastric Dieulafoy lesion: a case report.

Dieulafoy's lesion is one of an unusual cause of upper gastrointestinal bleeding (U GIB). Endoscopic intervention has always been a preferred non-surgical method in treating UGIB including bleeding from Dieulafoy's lesion. Owing to recent advances in angiography, arterial embolization has become a popular alternative in non- variceal UGIB especially in cases with failed endoscopic treatment. However, managing bleeding Dieulafoy's with selective arterial embolization as the first line of treatment has not been exclusively practiced. We hereby, report a case of bleeding Dieulafoy lesion which had been primarily treated with arterial embolization.

Multi-Detector CT Angiography Can Be Helpful in the Diagnosis of Massively Bleeding Dieulafoy Lesion

Multi-Detector CT Angiography Can Be Helpful in the Diagnosis of Massively Bleeding Dieulafoy Lesion

Actively Bleeding Dieulafoy Lesion Identified in a Critically Ill Patient Only After the Use of Hydrogen Peroxide

Actively Bleeding Dieulafoy Lesion Identified in a Critically Ill Patient Only After the Use of Hydrogen Peroxide

Fatal Henoch-Schönlein Purpura in an Adult With Dieulafoy Lesions

Henoch-Schönlein purpura (HSP) is considered a benign disease of children. We report a severe case of HSP in an adult causing renal failure and gastrointestinal (GI) hemorrhage. Despite aggressive treatment with corticosteroids, cyclophosphamide, and plasmapheresis, the patient developed massive GI bleeding from 2 Dieulafoy lesions and died weeks after bowel resection. Although uncommon, when massive GI hemorrhage occurs, actively bleeding Dieulafoy lesions, although uncommon, should be suspected and evaluated early.

Hemostatic efficacy and clinical outcome of endoscopic treatment of Dieulafoy's lesions: comparison of endoscopic hemoclip placement and endoscopic band ligation

The most suitable mechanical endoscopic hemostasis for a bleeding Dieulafoy's lesion (DL) is not yet well established. To compare the hemostatic efficacy and clinical outcome of endoscopic hemoclip placement (EHP) and endoscopic band ligation (EBL). Retrospective, single-center study. A tertiary-care referral university hospital. Sixty-six patients who received mechanical endoscopic hemostasis for bleeding DLs. Endoscopic hemostasis. Primary hemostasis and rebleeding rates. DLs accounted for 3.8% of cases of acute nonvariceal upper GI bleeding during the study period. Active bleeding from DLs was noted in 34 patients (51.5%). EHP and EBL were performed as a method of endoscopic hemostasis in 34 and 32 patients, respectively. There were no significant differences between the 2 groups with respect to baseline characteristics (except comorbidities) and endoscopic features of DLs. Primary hemostasis was achieved in all 66 patients (100%). There were 6 cases of recurrent bleeding: 5 (14.7%) and 1 (3.1%) in the EHP and EBL groups, respectively. Secondary hemostasis was achieved with endoscopic treatment and angiographic embolization in 5 patients and 1 patient, respectively, and no patients required surgery. The mean procedure time of endoscopic hemostasis was significantly longer in the EHP group (19.1 vs 11.5 minutes, P = .015). There was no bleeding-related mortality. Retrospective analysis. Both EHP and EBL are suitable for the treatment of bleeding DLs. EBL can be used as an initial hemostatic method for bleeding DLs because of a favorable clinical outcome comparable to that with EHP and a shorter procedure time.

Single-balloon enteroscopy for the management of a bleeding Dieulafoy lesion in the jejunal diverticulum

Please cite this article in press as: Ch jejunal diverticulum, Journal of the 0929-6646/$ see front matter Copyr doi:10.1016/j.jfma.2011.09.011 Abstract Approaching the “dark continent” of gastrointestinal tract, i.e., the small bowel, is always challenging to gastroenterologists. With the coming era of balloon-assisted enteroscopy, deep intubation of the small intestine for both diagnostic and therapeutic purposes has become possible. Here we describe a 60-year-old man who came to our emergency department because of overt gastrointestinal bleeding. An antegrade single-balloon enteroscopy showed a Dieulafoy lesion in the jejunal diverticulum. Argon plasma coagulation of the lesion followed by hemoclipping were performed. The patient showed no complications on a 90-day follow-up. Copyright a 2011, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.

Bleeding Dieulafoy lesions of the small bowel: a systematic study on the epidemiology and efficacy of enteroscopic treatment

Dieulafoy lesions consist of aberrant submucosal arteries, which can cause severe GI bleeding. The predominant location of Dieulafoy lesions is the upper GI tract. To our best knowledge, this is the first systematic study on the frequency of bleeding from Dieulafoy lesions in the small bowel and the efficacy of enteroscopic therapy regarding primary hemostasis and long-term follow-up. Multicenter, retrospective, observational study. Nine Austrian centers doing double-balloon enteroscopy or single-balloon enteroscopy. This study involved 284 consecutive patients who were referred for double-balloon enteroscopy or single-balloon enteroscopy because of suspicion of mid-GI bleeding. A total of 317 double-balloon enteroscopy and 78 single-balloon enteroscopy procedures were performed in 284 patients with suspected mid-GI bleeding. Demographic, clinical, procedural, and outcome data were collected. A Dieulafoy lesion in the small bowel was identified as the source of mid-GI bleeding in 3.5% of patients, with a mean of 1.5 enteroscopy sessions required per diagnosis. In 9 cases the Dieulafoy lesion was found by enteroscopy from an oral approach, and in 1 patient the lesion was found by an anal approach. In all patients primary endoscopic hemostasis was successful. Eight of 10 patients were free from rebleeding episodes (median follow-up 14.5 months, interquartile range 10.0-17.5 months). In 2 of 10 patients, rebleeding occurred, and a surgical intervention was necessary. Retrospective study. Bleeding from Dieulafoy lesions of the small bowel seems to occur more frequently than previously estimated. Most of these lesions are located in the proximal jejunum and can be managed successfully by enteroscopy. After successful endoscopic hemostasis, rebleeding episodes occur in only 20% of patients.

Sp704 Prototype Forward Viewing Linear Array Echoendoscope for Management of Upper GI Bleeding

Real time EUS imaging of submucosal arteries would be an advance in the management of upper GI bleeding, as it may allow for targeting of therapy and assessment of cessation of blood flow post therapy. However, curvilinear array echoendoscopes currently in use are inadequate. The oblique view limits endoscopic imaging and delivery of therapy. We present for the first time, in a human study, the feasibility of visualizing submucosal arteries with, and delivery of guided hemostatic therapy using a prototype forward-viewing echoendoscope. A 58 year old female patient presented with hematemesis, melena and a 4 gram drop in hemoglobin. She was admitted to the intensive care unit, and resuscitated with blood and IV fluid. Endoscopy was performed with a prototype forward-viewing therapeutic echoendoscope, XGIF-UCT160J-AL5; (Olympus Inc, Tokyo, Japan), which has a 90° US scanner with color Doppler, and a 3.7-mm working channel, without an elevator. An actively bleeding Dieulafoy lesion was seen in the post bulbar duodenum. Thermal therapy with a 10Fr heater probe was performed for hemostasis. Despite adequate post-treatment visual appearance, subsurface arterial blood flow was audible with a through-the-scope doppler ultrasound probe. High resolution endosonographic exam demonstrated multiple deep and superficial blood vessels with active blood flow. Superficial blood vessel's of upto 0.8 mm in diameter were seen at a depth of upto 3mm. Additional thermal therapy was applied with the heater probe with simultaneous endoscopic and sonographic visualization. Post treatment, doppler flow was absent at shallow depth, and sonographic exam of the the site demonstrated no superficial blood flow. Real-time sonographic imaging of submucosal blood flow in a bleeding lesion appears feasible with a forward-viewing echoendoscope. Precise targeting of therapy with this echoendoscope is a possibility. This could potentially improve efficacy of hemostasis in GI bleeding, leading to a decrease in re-bleeding rates, and mortality. Larger studies are necessary to delineate efficacy, appropriate indications and limitations of management of GI bleeding with this prototype echoendoscope.

An Unusual Cause of Syncope in a Healthy Male: Duodenal Dieulafoyʼs

Purpose: A 37-year-old man with no known medical history presented to the emergency department after a syncopal episode. He reported having one loose bowel movement containing bright red blood two hours before losing consciousness. There was no history of hematemesis, and he had no risk factors for GI bleeding such as previous gastrointestinal hemorrhage, NSAID, anticoagulant or alcohol use. On presentation, blood pressure was 115/59 and heart rate was 98/minute. Physical examination revealed red blood in the rectum. Labs showed a hemoglobin of 12.7 g/dL and Blood Urea Nitrogen (BUN) of 33 mg/dL. Urgent esophagogastroduodenoscopy was performed and revealed an actively bleeding Dieulafoy's lesion in the post-bulbar duodenum (Figure). The lesion was deemed not amenable to endoscopic therapy and the decision was made to manage the patient surgically. A duodenotomy was performed 8 cm distal to the pylorus and revealed a purplish red bloody lesion on the posterior wall of the duodenum; it was suture ligated with two sutures, after which the field dried up and green bile was seen for the first time. The patient did well post-operatively and was discharged from the hospital a few days later in stable condition. Conclusion: Dieulafoy's are an uncommon cause of gastrointestinal bleeding, occurring in about 2% of upper GI bleeding episodes. These lesions are submucosal arteries that are unusually close to the mucosa, resulting in erosion and bleeding. The majority of Dieulafoy's lesions are found in the proximal stomach and extra-gastric Dieulafoy's are thought to be rare, with only a handful reported in the literature. They can be associated with life-threatening hemorrhage and may be difficult to diagnose due to their small size, pattern of intermittent bleeding and sometimes obscure location. However, the diagnosis should be considered during the evaluation of any patient who presents with massive gastrointestinal bleeding, especially in the absence of other risk factors. As seen in our case of a young healthy male who presented with syncope, mild perturbations in resting pulse rate, blood count or BUN may sometimes be the only clues of underlying massive gastrointestinal hemorrhage.Figure: [1040] Bleeding duodenal Dieulafoy's lesion.

The Story of a Duodenal Bulb Dieulafoyʼs Lesion that Bled Massively and then Bled Again Three Years Later!

Purpose: Dieulafoy's lesions are an uncommon but important cause of recurrent UGIB. Dieulafoy's lesions of the duodenal bulb are extremely rare. We report a case of a Dieulafoy's lesion of the duodenum that bled and bled again three years later. Case Report: 47-year-old female presented to our emergency room with multiple episodes of coffee-ground emesis and melena. She denied abdominal pain, ASA, NSAID or anticoagulant use. Patient was orthostatic with a 3 gm/dl drop in hemoglobin. Nasogastric lavage revealed coffee grounds and rectal exam showed melena. Patient was admitted three years prior with a 6 unit PRBC bleed that was erroneously attributed to duodenitis. Review of those endoscopic photographs revealed a Dieulafoy's lesion of the duodenal bulb. After stabilizing the patient, EGD was performed which revealed a protruding 3 mm vessel in the duodenal bulb without local ulceration. The diagnosis of a bleeding Dieulafoy's lesion was made and two hemoclips were deployed to achieve hemostasis. Post-procedure there was no further bleeding. A follow-up EGD the following week revealed clips in place and resolution of the visible vessel. Another follow-up EGD in seven weeks showed normal duodenal bulb, loss of prior clips and disappearance of the Dieulafoy's lesion. Discussion: A Dieulafoy's lesion is a dilated aberrant sub-mucosal vessel about 1-3 mm in diameter or ten times the size of normal sub-mucosal capillaries. This large vessel can erode through the overlying epithelium in the absence of a primary ulcer. Dieulafoy's lesions account for less than 1 percent of cases of severe UGI hemorrhage and endoscopy is the diagnostic modality of choice. The finding of a protruding vessel, with or without active bleeding, that is not associated with an ulcer should suggest the possibility of a Dieulafoy's lesion. Dieulafoy's lesions are small and can be easily missed or they can disappear retracting back into the mucosa. In this case, we have photographs documenting a duodenal Dieulafoy that bled, resolved without therapeutics, and then bled again three years later. This indicates that a Dieulafoy is a ticking time bomb that can cause recurrent bleeding. Endoscopic management has success rates reported to be as high as 95 %. Therapeutic modalities including epinephrine injection, electrocautery, hemoclip application, rubber band ligation and argon plasma coagulation have been used. Recent data shows that therapy with hemoclip results in greater initial hemostatic efficacy and reduced recurrent bleeding as compared with injection therapy.

Aplicaciones de los clips en la terapéutica endoscópica actual

The applications of clips in current therapeutics are increasingly numerous. Endoscopic hemoclipping for acute nonvariceal bleeding is a highly effective and safe modality for hemostasis with initial hemostatic rates of between 85 and 98% and a rebleeding rate of approximately 5-10% both in patients with peptic ulcer bleeding and signs of endoscopic risk (Forrest Ia-IIb) and in bleeding secondary to submucosal lesions, diverticular bleeding, Mallory-Weiss tear, bleeding Dieulafoy's lesions, and postpolypectomy bleeding. In addition to the effectiveness of this technique as a hemostatic mechanism, many publications have demonstrated the utility of these clips to close perforations and fistulas, to serve as a radiopaque marker and as a tool to fix accessories (feeding tubes or prostheses). However, endoscopic clipping has certain limitations depending on the nature of the injury and the type of patient, as well as high economic cost and some technical limitations.

A retrospective analysis of emergency double-balloon enteroscopy for small-bowel bleeding

Although the role of emergency esophagogastroduodenoscopy (EGD) and colonoscopy for upper and lower gastrointestinal bleeding (GIB) is well defined, there are no data on the concept of emergency double-balloon enteroscopy (DBE) for small-bowel bleeding. The aim of this study was to retrospectively evaluate the concept of emergency DBE in overt obscure GIB and assess its impact on patient management. A total of 17 emergency DBEs for overt obscure GIB were carried out in ten patients (six women, four men; mean age 68 years, range 35 - 83). The following diagnoses were made: actively bleeding Dieulafoy lesions of the small bowel, n = 2; bleeding tumors, n = 4 (carcinoids n = 2, adenocarcinoma n = 1, lipoma n = 1); bleeding angiodysplasias and/or large arteriovenous malformation (AVM), n = 2; multiple ulcers, n = 1; and no diagnosis, n = 1. Endoscopic therapies included argon plasma coagulation (n = 6), injection of epinephrine (n = 3), and use of fibrin glue (n = 1). It appears that emergency DBE is technically feasible, facilitates both diagnosis and therapy and enables management of patients with massive overt obscure GIB. This study is a first step in establishing the concept of emergency DBE for patients with suspected small-bowel bleeding.

Midgut Bleeding: The Concept of Emergency Double Balloon Enteroscopy (DBE)

Background: DBE is an accepted and established endoscopic method to diagnose and treat small bowel bleeding. There is no data on the concept of emergent DBE for overt OGIB. Aim: To evaluate the concept of emergent DBE in overt OGIB. Patients and Methods: All patients undergoing DBE for OGIB during a 4-year period in a university hospital were studied. OGIB was defined according to AGA guidelines. An emergency DBE was defined as a procedure performed within 24-hrs of clinical presentation, implying that emergent DBE was also performed on weekends or holidays. All procedures were performed using the therapeutic DBE (Fujinon, Japan). The main outcome measurements were to evaluate on the utility of emergent DBE, its technical feasibility and impact in the clinical management of pts. Results: During the study period 87 patients underwent DBE for overt OGIB. A total of 10 patients (7F, 3M, mean age 68 yrs, range 48-83, ASA score II/III) underwent emergent DBE. A total of 15 DBEs were performed (11 oral and 4 anal). All patients presented with hematochezia or melena. An EGD and colonoscopy was performed in all patients. The mean hemoglobin was 7.4 gr/dl, range 4.2 to 8.4. The following diagnosis were made: bleeding Dieulafoy of the SB, n=2, tumors, n=4 (carcinoids, n=2, adenocarcinoma, n=1, lipoma n=1), bleeding arteriovenous malformation (AVM) n=3, multiple ulcers, n=1 and jejunitis, (Henoch-Schönlein), n=1. All lesions were treated endoscopically with argon plasma coagulation (n=6), injection of epinephrine (n=3), fibrin glue (n=1). In one patient with a bleeding Dieulafoy lesion 3 DBEs were performed to stop the bleeding. Another patient (large AVM) had persistent bleeding despite endoscopic therapy and underwent a (failed) angiography, and was thus emergently operated (resection of small bowel segment containing large AVM). The 4 patients with bleeding tumors underwent elective laparotomy with partial small bowel resection. Conclusions: Emergent DBE is technically feasible, safe, facilitates both diagnosis and therapy, and enables the clinical management of patients with massive overt OGIB. Emergent DBE may be of benefit in patients with renal failure who may not tolerate intravenous dye. This study is a first step in establishing the concept of emergency balloon-assisted enteroscopy for patients with suspected mid-gut bleeding.

Dieulafoyʼs Lesion of Esophagus Managed with Injection Therapy

Purpose: We report the case of a 25-year-old male from Gambia, West Africa who presented complaining of vomiting bright red blood for 3 days. He had been seen in emergency department of a different hospital 3 days prior and sent home, as the vomiting had resolved. He subsequently had 1 episode hematemesis so he came to our ED for further evaluation. He reported passing black stool on one occasion. He denied abdominal pain, fever, dizziness, and shortness of breath. He denied smoking, alcohol use, or use of any drugs, except that he had taken a total of 4 Advil tablets prior to seeing melena. On examination, he was afebrile, slightly tachycardic with a pulse of108; BP was 142/85 with no orthostasis. The abdominal exam revealed a soft, non-tender abdomen with normoactive bowel sounds. Stool guiac was positive. Laboratory values were as follows: hemaglobin and hematocrit (H&H) 5.7 g/dl/16.3%; INR 1.3; BMP values were within normal limits. Chest x-ray and plain abdominal film revealed no significant findings. EKG demonstrated sinus tachycardia at 105 bpm, but was otherwise unremarkable. GI consultation was requested, and 4 units of PRBC transfusion were recommended to keep hemoglobin above 9. Subsequently, the patient was taken for upper endoscopy. Upper endoscopy revealed an actively bleeding Dieulafoy's lesion in the mid esophagus, along with a hiatal hernia, which was controlled with sclerotherapy using epinephrine and cautery with BICAP. The patient was monitored in the ICU, the blood counts stabilized, and there were no further episodes of hematemesis or melena. The patient was subsequently discharged home on a proton pump inhibitor. Discharge H&H were 7.6 g/dl and 21%. Three days later, he returned to the ED complaining of constipation. On this admission, guiac was positive and the H&H were was 7.1 g/d and 21.0%. GI consultation was again requested, and the patient was taken for repeat upper endoscopy which demonstrated both cauterized lesions in the esophagus to be well-healed with a clean, white base and no evidence of recurrent bleeding. The H&H remained stable, and the patient was discharged home on iron tablets and followed in the GI clinic with no episodes of recurrent bleeding.[figure1]Figure

Delayed fatal hemorrhage after endoscopic band ligation for gastric Dieulafoy's lesion

Dieulafoy's lesions are well-known, rare, and diagnostically challenging clinical entities that usually cause massive GI bleeding. 1 Miko T.L. Thomazy V.A. The caliber persistent artery of the stomach: a unifying approach to gastric aneurysm, Dieulafoy's lesion, and submucosal arterial malformation. Hum Pathol. 1988; 19: 914-921 Abstract Full Text PDF PubMed Scopus (98) Google Scholar , 2 Juler G.L. Labitzke H.G. Lamb R. Allen R. The pathogenesis of Dieulafoy's gastric erosion. Am J Gastroenterol. 1984; 79: 195-200 PubMed Google Scholar , 3 Schmulewitz N. Baillie J. Dieulafoy lesions: a review of 6 years of experience at a tertiary referral center. Am J Gastroenterol. 2001; 96: 1688-1694 Crossref PubMed Google Scholar , 4 Lee Y.T. Walmsley R.S. Leong R.W. Sung J.J. Dieulafoy's lesion. Gastrointest Endosc. 2003; 58: 236-243 Abstract Full Text PDF PubMed Scopus (142) Google Scholar We describe a patient who received endoscopic band ligation (EBL) for a bleeding Dieulafoy's lesion at the gastric cardia. Despite endoscopic follow-up, the patient died from recurrent fatal hemorrhage. To our knowledge, this is the first reported death caused by delayed hemorrhage after EBL for a Dieulafoy's lesion.