Duodenal Dieulafoy's Lesion Research Articles

A rare case of duodenal Dieulafoy’s lesion managed by endoscopic band ligation

Dieulafoy's lesion is an uncommon but important cause of recurrent upper gastrointestinal bleeding. Extragastric location of Dieulafoy's lesion is rare. We report a case of duodenal Dieulafoy's lesion which was successfully managed by banding. Fifty-year-old presented with recurrent upper gastrointestinal (GI) bleed and severe anemia with history of multiple blood transfusions and OGD scope showed dieulafoy’s lesion in the second part of duodenum (D2), which was successfully managed by banding. Endoscopic diagnosis of extragastric Dieulafoy's lesion can be difficult because of the small size and obscure location of the lesion. Increased awareness and careful and early endoscopic evaluation following the bleeding episode are the key to accurate diagnosis. Banding is one of the safest, cost effective endoscopic modalities for control of bleeding.

Etiological Profile of Lower Gastrointestinal Bleeding in Children and Adolescents from Kashmir; A Tale of 5 Years.

Background: Lower gut bleeding is an alarming sign among caregivers. Determining the etiology is of utmost importance for further management. This is the first study conducted in northernmost India. Methods: This cross-sectional study was conducted at the Department of Pediatrics, Government Medical College, Srinagar. This study aimed to describe the etiology of lower gastrointestinal bleeding in the age group of 1-18 years over the past 5 years from June 2017 to June 2022. Results: A total of 310 children presented with hematochezia (53.5%), blood mixed with loose stools for > 2 weeks (39.3%), melena (1.9%), and occult blood in stools (0.3%). The mean age was 5.12 years. The age group of 1-6 years was 73.5 %. The most common findings were rectosigmoid polyps n=104 (33.5%), anal fissure n=47 (15.1%), lymphoid nodular hyperplasia (LNH) n=38 (12.2%), trichuris dysentery syndrome n=30(9.7%), cow's milk protein allergy n=27(8.7%), non-specific colitis n=18(5.8%), solitary rectal ulcer syndrome n=14(4.5%), inflammatory bowel disease n=6 (1.9%),intestinal tuberculosis n=3(0.9%), duodenal dieulafoy lesion 1(0.3%), and blue bleb nevus rubber syndrome n=1(0.3%). 21 patients had a normal colonoscopy. The colonoscopy yield was 93.3 %. Among the colonoscopy-negative patients, 6(1.6%) had Meckel's diverticulum, and 1(0.3%) had a duodenal dieulafoy lesion. Conclusion: Lower GI bleeding most commonly presents as hematochezia, and the most common cause is a rectosigmoid polyp. Colonoscopy is the procedure of choice to evaluate the etiology of lower GI bleeding. Anal fissures, LNH, Trichuris trichiura, and cow's milk protein allergy are other common causes of lower gut bleeding in Kashmir, northernmost India.

3145 Dieulafoy's Lesion: An Underdiagnosed and Underrecognized Cause of Gastrointestinal Bleed

INTRODUCTION: Acute gastrointestinal bleed accounts for nearly 50-150 cases per 100,000 each year. The etiology in the majority of cases is peptic ulcer disease (PUD). Dieulafoy's lesion is a rare (accounts for 1-2%), but potentially life-threatening cause of gastrointestinal (GI) bleed. We present a case of recurrent hemodynamically significant upper GI bleeding requiring multiple hospitalizations and endoscopies to identify a duodenal Dieulafoy's lesion as the primary source for bleed. CASE DESCRIPTION/METHODS: A 52-year-old male with a history of chronic alcohol use was admitted to the intensive care unit for the third time within a one-year duration for recurrent episodes of melena. During the first two episodes, upper GI endoscopy was positive for mild gastropathy, and a small 4-5 mm partially healed duodenal ulcer respectively. The exam was negative for any esophageal varices or other upper GI pathologies. The patient responded well both times to medical therapy and subsequently discharged home. In the third admission for similar presentation with melena and hemodynamically significant GI bleed, endoscopy was positive for an actively bleeding duodenal Dieulafoy's lesion. Bleeding was controlled with hemostatic clips and epinephrine injections. He was discharged home 48 hours after stabilization. Post-discharge, he was followed for a year, and he remained asymptomatic. It was therefore concluded that Dieulafoy's lesion was the likely cause of GI bleed that had evaded diagnosis during the first two endoscopies. DISCUSSION: Dieulafoy's lesion is a dilated submucosal vessel that erodes the epithelium and most commonly found in the stomach. Approximately one-third of the lesions are extragastric and located in the duodenum and colon. They are typically seen in men, around the fifth decade, in the presence of comorbidities such as hypertension, diabetes, chronic kidney disease, or alcohol abuse. Dieulafoy's lesions are under-diagnosed as they are silent until presentation. Approximately 33% of the lesions may require more than one EGD to identify the active source of bleeding, especially in the presence of other causes of GI bleed such as PUD. In our patient, the culprit for his recurrent GI bleeding was identified as Dieulafoy's lesion on the third endoscopy. We want to highlight the importance of the diagnosis and management of Dieulafoy's lesion as it can significantly decrease the mortality from 80% to 8.6%.

1494 Padlock Clip in the Management of Non-Lifting Part of Incompletely Resected Polyp With Central Fibrosis

INTRODUCTION: Removing nonlifting colon polyps with fibrosis secondary to prior intervention could be challenging. The novel over-the-scope Padlock clip was used in esophageal fistulas, refractory gastrointestinal bleeding, and GI defects closure. In this study, we describe our experience with Padlock clip in remeoving nonlifitng colon polyp. CASE DESCRIPTION/METHODS: A 69-year-old man is referred to our clinic to assist in the management of partially excised large, non-granular, broad-based Tubulovillous adenoma. The polyp was in cecum and measured about 5 cm. The patient underwent surveillance colonoscopy given personal history of colon polyps and paternal history of colorectal cancer. The referring physician attempted to remove by standard and Captivator snares using hot snare techniques. The polyp was not completely engaged, and the resected fragments were removed using roth net. We attempted to lift the polyp to remove using endoscopic submucosal dissection, but the scar mark could not be lifted. After marking around the polyp using electrosurgical knife (Figure 1), endoscopic submucosal dissection was done around the polyp with gradual extension of the circumferential mucosal incision, followed by hot snare-assisted resection of the lesion in a piecemeal fashion. The Non-lifting part of mucosal polyp was then grasped with raptor grasping device and Padlock clip was deployed on the polyp. The remnant polyp was successfully removed with hot snare utilizing “histlock resection device” and the margins were treated with tip of hot snare (Figure 2). Repeat colonoscopy after 3 months showed scar at previous polypectomy site with clean margins and no signs of recurrence (Figure 3). DISCUSSION: To our knowledge, this is the first study describing the use of of Padlock clip in the management of nonlifting colon polyp after incomplete resection using the conventional methods. The Padlock clip was used in the management of refractory gastrointestinal bleeding (post endoscopic mucosal resection, solitary rectal ulcer, and duodenal dieulafoy lesion), broncho-esophageal and tracheoesophageal fistulas closure, and wall defects closure in porcine. Further prospective studies are needed to assess its use in removing incompletely resected polyps.

Dieulafoy lesions causing upper gastrointestinal bleeding in children

Abstract Since the description of Dieulafoy lesions, its' definition has broadened and now represents an acute process that occurs in adult and paediatric patients, with intra-gastric and extra-gastric locations. There are also multiple advancements in the non-operative management of such lesions. Prompt diagnosis and management is required for improved outcomes. Management is mainly dependent on the haemodynamic status of the patient and location of the lesion. Endoscopic diagnosis and the multiple endoscopic treatment options now available have made operative intervention less frequent. However, there are no current management guidelines for DLs in the paediatric population. We look at two patients in two Johannesburg tertiary institutions that presented with gastric and duodenal Dieulafoy lesions and the treatment strategies applied. One patient was managed successfully with haemostatic endo-clips. The other patient was initially managed with endoscopic adrenaline injections at four quadrants but later required a partial gastrectomy.

Endoscopic Doppler Probe in the Diagnosis and Management of Upper Gastrointestinal Hemorrhage

Through-the-Scope (TTS) endoscopic Doppler ultrasound probe technology is a tool that has garnered interest for the evaluation of variceal and non-variceal bleeding. We describe two cases in which endoscopic Doppler probe guided diagnosis and management of two patients with upper gastrointestinal hemorrhage. A 55 year old African American male with history of nephrectomy for a T1N0M0 renal cell carcinoma,end stage renal disease on hemodialysis presented to the emergency department after an episode of melena.Hemoglobin on presentation was 7.1 g/dl. During the hospitalization,he underwent several endoscopies and tagged RBC scan, none of which could identify a source of bleeding.EUS was performed to assess the gastric fundus for gastric varices or gastric Dieulafoy, which was unremarkable.Endoscopy with Doppler probe was subsequently performed and identified a 2 mm. red spot in the duodenal bulb with strong arterial signal compatible with a duodenal Dieulafoy lesion,which was successfully treated.The patient did not have further episodes of bleeding and hemoglobin stabilized at 8 g/dl. A 32 year old male with recent history of binge drinking and emesis presented with gastrointestinal bleeding.On arrival, the patient was hemodynamically stable.Laboratory values were significant for hemoglobin of 13.5 g/dl and platelets of 88 x109/L.On initial endoscopic evaluation, a Mallory-Weiss tear was seen and thought to be the etiology of bleeding.Further evaluation with endoscopic Doppler US probe revealed an audible venous Doppler signal that was consistent with a varix, and closer endoscopic inspection revealed a junctional gastroesophageal varix with a tear.Three bands were successfully placed and post-band ligation Doppler signal was absent. In summary, we present two patients in whom a TTS endoscopic Doppler ultrasound probe guided the diagnosis and subsequent management of acute upper gastrointestinal hemorrhage.In the first patient,it helped to identify an obscure source of GI bleeding after multiple endoscopies and a bleeding scan.In the second patient,it served to discover an unsuspected bleeding etiology of a junctional varix when a Mallory-Weiss tear was initially suspected which then resulted in change of clinical management.Though the literature has identified its utility in peptic ulcer hemorrhage,these cases highlight its use in other causes,which may translate to downstream effects, such as decreasing morbidity and mortality related to GI hemorrhage.Figure: Case One: Two mm red spot in duodenal bulb (arrow), seen during repeat EGD on day 6.Figure: Case Two: Initial endoscopy showing a tear around GE junction (arrow), thought to represent Mallory- Weiss tear.Figure: Case Two: Junctional varix post-band ligation.

Over-the-scope clip placement for closure of gastrointestinal fistula, postoperative leaks and refractory gastrointestinal bleed.

The over-the-scope clip (OTSC) has been successfully used in the closure of fistula, perforation, dehiscence, and endoscopic hemostasis. We describe our experience with the OTSC application. Between April 2014 and April 2015, seven patients underwent OTSC application. In four patients, OTSC was applied for the closure of esophageal fistula, one had OTSC closure of persistent gastrocutaneous fistula after percutaneous endoscopic gastrostomy removal, and OTSC was applied in duodenum in two patients, for duodenal Dieulafoy's lesion after failed conventional endotherapy and massive rebleed in one and duodenal perforation in another. All procedures had technical success with no immediate complication related to OTSC application. Patients were followed up for every month with mean duration of follow up 10.2months. One patient with bronchoesophageal fistula had development of another fistulous opening above the site of OTSC placement, which was successfully closed with another OTSC. One patient had superficial esophageal wall ulcer opposite the OTSC but it healed spontaneously. OTSC provided safe and successful closure in a number of settings.

Clinical outcome of endoscopic management of duodenal Dieulafoy's lesions: endoscopic band ligation versus endoscopic hemoclip placement.

The most appropriate type of endoscopic hemostasis for bleeding due to duodenal Dieulafoy's lesions (DLs) is not yet established. The aim of this study was to assess the efficacy of mechanical endoscopic hemostasis for duodenal DLs and long-term outcome after successful hemostasis, as well as to compare the efficacy and safety of endoscopic band ligation (EBL) and endoscopic hemoclip placement (EHP). Patients admitted to the emergency unit with acute upper gastrointestinal bleeding from duodenal DLs were enrolled in this study. The data were collected prospectively, but data analysis was performed retrospectively. Twenty-four patients with duodenal DLs were treated with EBL (n=11) or EHP (n=13). There were no significant differences between groups with respect to clinical or endoscopic characteristics, apart from the number of epinephrine (three cases with EBL vs. 11 cases with EHP; p=0.011). Primary hemostasis was achieved in all patients. Recurrent bleeding was observed in one patient (9.1%) from the EBL group and in five patients (38.5%) from the EHP group (p=0.166). The recurrent bleeding in the patient from the EBL group was treated by EHP. In the EHP group, all five patients achieved successful secondary hemostasis by endoscopic treatment (EBL in two patients and EHP in three patients). There were no differences in secondary outcomes between the two groups, including the number of endoscopic sessions required, need for angiographic embolization or emergent surgery, transfusion requirements, or length of hospital stay. No complications occurred, and there was no recurrence of bleeding in either group during the follow-up period. Mechanical endoscopic treatments are effective and safe for the treatment of bleeding duodenal DLs. A large-scale, randomized, controlled study is required to confirm the efficacy and safety of EBL and EHP for the management of bleeding duodenal DLs.

Mini-loop ligation of a bleeding duodenal Dieulafoy's lesion

Two percent of gastrointestinal hemorrhages are caused by Dieulafoy's lesions, which are located in duodenum in only 15% of cases. There are no recommendations regarding the prime endoscopic treatment technique for this condition. A 61-year-old woman presented with melena without signs of hemodynamic instability. During an urgent upper endoscopy, blood oozing from the normal mucosa of the duodenum was seen and this was classified as a Dieulafoy's lesion. A mini-loop was opened at the rim of a transparent ligation chamber, at the end of the endoscope, and after aspiration of the lesion, closed and detached. Complete hemostasis was achieved without early or postponed complications. In every day clinical practice, mini-loop ligation is rarely used because of possible complications, such as site ulceration, organ perforation, re-bleeding and possible inexperience of the operator. To the best of our knowledge this is the first case of successful treatment of bleeding duodenal Dieulafoy's lesion by mini-loop ligation.

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.

Successful side-viewing endoscopic hemoclipping for Dieulafoy-like lesion at the brim of a periampullary diverticulum

BackgroundDuodenal Dieulafoy's lesions are rare and only several cases were reported so far. Their characteristic appearance and location make it difficult to be diagnosed in the clinical practice. Massive bleeding often results from these lesions and can impede the accurate early treatment.Case presentation67 years old male patient suffered a fatal bleeding from Dieulafoy-like lesion located at the mouth of the periampullary diverticulum. Inintial endoscopic therapy and radiologic embolization failed to stop the bleeding, while direct observation and hemoclipping by the side viewing endoscopy successfully established correct diagnosis and permanent cure of the lesion.ConclusionAggressive endoscopic examinations combined with the accurate endoscopic threatment should be adopted when Dieulafoy-like lesion is suspected as a possible cause of the proximal small bowel hemorrahge. Verification of the diagnosis and definitive treatment often needed repeated examination by side-viewing endoscope as well as stabilization of the patient.

Endoscopic Ultrasound (EUS)-Guided Angiotherapyof Refractory Gastrointestinal Bleeding

There are well-established methods for treating gastrointestinal (GI) bleeding, although some lesions prove refractory to conventional techniques. Little consideration has been directed toward the use of endoscopic ultrasound (EUS) in the management of refractory bleeding. To discuss patient selection, technique, and clinical outcomes for EUS-guided angiotherapy for severe refractory bleeding after conventional therapies. The EUS database was reviewed to identify all patients who underwent EUS-directed angiotherapy. Five patients, four with severe bleeding from hemosuccus pancreaticus, Dieulafoy lesion, duodenal ulcer, or gastrointestinal stromal tumor (GIST) and one with occult GI bleeding, had an average of three prior episodes (range 2-4) of severe bleeding and had received 18 (range 14-25) units of packed red blood cells (PRBC). All had failed in at least two conventional attempts to control the bleeding. Under EUS guidance, 99% alcohol was injected (4-7 mL) in two patients, one each with a pancreatic pseudoaneurysm and a duodenal Dieulafoy lesion. In three other patients, cyanoacrylate (3-5 mL) was injected into a duodenal ulcer, and in two patients with a GIST. No patient rebled and no complications were reported. EUS-guided angiotherapy appears safe and effective in managing selected patients with clinically severe or occult GI bleeding from lesions potentially refractory to standard endoscopic and/or angiographic techniques. Further studies are needed to confirm the safety and efficacy and to refine the selection criteria in an effort to improve patient care.

Procedure of Endoscopic Hemostasis Using a Distal Attachment and Short Clips Against Upper Gastrointestinal Bleeding

BACKGROUND and AIM: Endoscopic hemostasis using hemoclips is useful against upper gastrointestinal bleeding, however it is difficult to perform hemoclipping against tangent view-lesions. A hood which is attached to a distal tip of an endoscope makes hemoclipping more easier, however it is sometimes difficult to observe lesions because clot is put into the hood. The aim of this study is to assess endoscopic hemostasis using a distal attachment and short clips against upper gastrointestinal bleeding. SUBJECTS and METHODS: Subjects were 103 patients with 117 lesions of upper gastrointestinal bleeding. A distal attachment, which was a short hood (4 mm in length) was attached to the distal tip of an endoscope from start of endoscopic examination. If lesions of upper gastrointesitinal bleeding were detected, hemoclipping using short clips was performed against them. This procedure had been performed against 50 lesions, including 20 of gastric ulcer, 14 of duodenal ulcer, 12 of lesion resected endoscopically against early gastric cancer and gastric adenoma, 3 of Mallory-Weiss syndrome and 1 of stomal ulcer. Endoscopic hemostasis by this procedure was analyzed. RESULTS: It was easy to insert the endoscope with the distal attachment into the upper GI in all patients. Appropriate endoscopic view using the distal attachment was achieved without disturbance of clot in all lesions. For tangent view-lesions, this attachment made endoscopic observation and treatment more easier. In addition, the entire short clip was able to be stored into this attachment, and certainly clamped a protruded visible vessel even if the bottom of the lesion was hard. Forty-seven of 50 lesions (94.0%) had temporal hemostasis and forty-six lesions (90.0%) had permanent hemostasis. One patient with multiple gastric ulcers, advanced hepatocellular carcinoma and bleeding tendency associated with DIC had temporal hemostasis, however he died of rebleeding from the ulcers. Two patients with duodenal ulcer and one patient with gastric ulcer underwent interventional radiology because visible vessels were more than 3 mm. One patient with duodenal Dieulafoy's lesion close to papilla of Vater underwent endoscopic hemoclipping using a lateral-viewing endoscope. CONCLUSION: Endoscopic hemostasis with a distal attachment and short clips is useful against upper gastrointestinal bleeding.

Haemorrhage from Multiple Duodenal Dieulafoy Lesions or Angiodysplasia: Endoscopic Characteristics Can Differentiate Between These Two Distinct Pathological Entities

Haemorrhage from Multiple Duodenal Dieulafoy Lesions or Angiodysplasia: Endoscopic Characteristics Can Differentiate Between These Two Distinct Pathological Entities

Endoscopic band ligation for non-variceal non-ulcer gastrointestinal hemorrhage

Background: There is no consensus as to the best treatment for non-variceal, non-ulcer gastrointestinal hemorrhage. Endoscopic band ligation is an inexpensive, readily available, and easily learned technique in contrast to conventional thermal methods of endoscopic hemostasis. We present the preliminary results of an open trial using endoscopic band ligation for non-variceal, non-ulcer bleeding in the gastrointestinal tract. Methods: Eighteen patients were treated by band ligation between June 1996 and November 1997. The lesions treated were: arteriovenous malformations in 10, Dieulafoy's lesions in 4, Mallory-Weiss tear in 2, and post-colonic polypectomy bleeding in 2. Results: Endoscopic band ligation was successful in 17 of 18 cases, with a follow-up period ranging from 2 to 18 months. The remaining case, a duodenal Dieulafoy's lesion, bled again at 24 hours but was successfully treated by adrenalin injection. Conclusions: Endoscopic band ligation is effective for non-variceal, non-ulcer bleeding. It has the advantage of ease of use and is relatively inexpensive.