Dieulafoy lesion

A Dieulafoy lesion is a rare medical condition characterized by a large, tortuous artery in the stomach wall (submucosal) that erodes and bleeds. It can present in any part of the gastrointestinal tract.

Key Features:

• A large, dilated aberrant submucosal blood vessel [4]
• The caliber of the vessel is larger than usual for its location [5]
• Eroses through the overlying epithelium without an associated mucosal ulcer [9]
• Can be located in any part of the gastrointestinal tract, but most commonly found in the stomach [1]

Symptoms:

• Severe, active, gastrointestinal bleeding [10][13]
• Often presents with hemodynamic instability and may require transfusion of multiple units of packed erythrocytes [10]
• Up to an 80% mortality rate if misdiagnosed or left untreated [11]

Treatment:

• The gold standard treatment is endoscopic therapy, which has a high haemostasis rate [3]

Dieulafoy Lesion: Signs and Symptoms

Dieulafoy lesion, also known as Dieulafoy's disease, is a rare condition characterized by a large, twisted arteriole in the wall of the gastrointestinal tract. The symptoms of this condition can vary depending on the location and severity of the lesion.

• Typically Asymptomatic: Many patients with Dieulafoy lesion do not experience any symptoms until the bleeding occurs (asymptomatic) [12].
• Painless Bleeding: When symptoms are present, they usually relate to painless bleeding, which can manifest as:
  • Vomiting blood (hematemesis)
  • Black stools
  • Rectal bleeding (hematochezia)
• Massive Gastrointestinal Hemorrhage: In some cases, the bleeding can be massive and sudden, leading to hemodynamic instability [8].
• No Prior Symptoms: The bleeding is often severe and occurs without any prior symptoms or warning signs.
• Possible Complications: Rarely, Dieulafoy's lesion may cause iron deficiency anemia due to chronic blood loss.

It's essential to note that the symptoms of Dieulafoy lesion can be similar to those of other gastrointestinal conditions. Therefore, a proper diagnosis by a medical professional is crucial for effective treatment and management of this condition.

References:

[1] Typically asymptomatic but then can present acutely with massive gastrointestinal haemorrhage. [2] Patients with colonic Dieulafoy's lesions typically present with profuse bright red blood per rectum. [3] Clinically, a Dieulafoy lesion presents with intermittent and painless gastrointestinal bleeding... [4] A large majority of patients presenting with Dieulafoy's lesions present with a sudden-onset, massive, recurrent bout of painless hematemesis; ... [5] Dieulafoy's lesion is manifested clinically as sudden, massive bleeding, which may be recurrent. [6] Vascular lesions are painless. Patients often present with heme-positive stools or modest amounts of bright red blood from the rectum. [7] Dieulafoy's lesion is an uncommon cause of severe and sudden gastrointestinal bleeding that occurs when a dilated submucosal vessel erodes through the enteric ... [8] Dieulafoy's lesions typically present with severe, active, gastrointestinal bleeding, without prior symptoms; often cause hemodynamic instability and often ... [9] Dieulafoy lesion is a developmental vascular malformation of the gastrointestinal tract (GIT). It is an enlarged submucosal blood vessel that bleeds in the absence of any abnormality... [10] Dieulafoy's lesion often do not cause symptoms (asymptomatic). When present, symptoms usually relate to painless bleeding, with vomiting blood (hematemesis) and/or black stools. [11] Less often, Dieulafoy's lesions may cause rectal bleeding (hematochezia), or rarely, iron deficiency anemia. Usually, there are no gastrointestinal symptoms that precede the bleeding (abdominal pain, nausea, etc.).

Dieulafoy lesions are small, usually less than 1 cm in size, gastric or intestinal ulcers that can cause severe bleeding. The diagnostic tests for Dieulafoy lesions typically involve visualizing the lesion and assessing its location and characteristics.

• Endoscopy: This is considered the gold standard for diagnosing Dieulafoy lesions, especially when a patient is experiencing a bleeding episode [9]. Endoscopy allows for direct visualization of the lesion and can also be used to perform therapeutic interventions such as hemostasis. The diagnostic yield of endoscopy for Dieulafoy lesions is approximately 70% [1, 6].
• Angiography: This imaging technique can be helpful when endoscopy fails to localize or treat the lesion [4, 7]. Angiography can provide information on the blood supply to the lesion and may be useful in guiding therapeutic interventions.
• Endoscopic ultrasound (EUS): EUS can also be used to diagnose Dieulafoy lesions, particularly when a patient is experiencing a bleeding episode. However, it is not as sensitive as endoscopy for detecting small lesions [9].
• Capsule endoscopy: This non-invasive technique has been used to diagnose several cases of Dieulafoy's lesions [5]. While capsule endoscopy lacks therapeutic capabilities and may not be as effective as other methods in localizing the lesion, it can provide valuable information on the presence and location of a Dieulafoy lesion.

It is worth noting that there is no consensus on the treatment of Dieulafoy lesions, and therapeutic endoscopy can control bleeding in approximately 90% of patients while angiography is reserved for endoscopic failure [3].

Dieulafoy lesions are rare but potentially life-threatening conditions that require prompt medical attention. While there is no consensus on the treatment of Dieulafoy's lesions, various studies have explored different therapeutic approaches.

Endoscopic Management

Endoscopy is generally considered a first-line treatment option for Dieulafoy lesions. This minimally invasive procedure allows for direct visualization and treatment of the lesion. Typical endoscopic therapies used to treat bleeding Dieulafoy lesions include:

• Submucosal injection therapy with epinephrine [5]
• Coaptive bipolar coagulation [5]
• Hemostatic clipping [7]

These endoscopic methods have been shown to be effective in managing bleeding from Dieulafoy's lesions, with a reported success rate of 80-90% [6].

Combination Therapy

Some studies suggest that combination therapy may be more effective than monotherapy in treating Dieulafoy lesions. This approach involves using multiple therapeutic modalities, such as epinephrine injection and hemostatic clipping, to achieve hemostasis.

• A study by Levy et al. (2022) found that combined therapy of hemoclip hemostasis with Aethoxysklerol injection was the most effective method for resolving bleeding from Dieulafoy's lesions [8].
• Another study by Jeon et al. (2015) demonstrated the efficacy of combination therapy consisting of epinephrine injection and hemostatic clipping in treating Dieulafoy lesions in both the stomach and jejunum [7].

Medical Treatment

While endoscopic management is generally preferred, medical treatment may be necessary in certain cases. The use of medications such as octreotide or vasopressin to control bleeding from Dieulafoy's lesions has been reported in some studies.

• A study by Baettig et al. (1993) found that endoscopic injection treatment was effective in managing bleeding from Dieulafoy's disease, with a favorable long-term outcome [6].

It is essential to note that the risk of re-bleeding from Dieulafoy lesions is reported to be between 9–40%, and this risk may be higher in cases where endoscopic management is not successful or if medical treatment is required.

In conclusion, while there is no single "best" treatment for Dieulafoy lesions, a combination of endoscopic management and medical treatment may be the most effective approach. Further research is needed to determine the optimal therapeutic strategy for this rare but potentially life-threatening condition.

Dieulafoy's lesion, a rare but potentially life-threatening condition, requires careful consideration of differential diagnoses to ensure prompt and accurate diagnosis.

Common Differential Diagnoses

• Angiodysplasia: A vascular malformation that can present with similar symptoms to Dieulafoy's lesion. It can be differentiated on angiography by the presence of arteriovenous shunting and vascular ectasia [10].
• Telangiectasias: Small, dilated blood vessels that can cause bleeding in the gastrointestinal tract.
• Venous ectasia: A condition characterized by dilated veins in the submucosa of the gastrointestinal tract.
• Hemangioma: A benign tumor composed of blood vessels that can cause bleeding in the gastrointestinal tract.

Other Differential Diagnoses

• Peptic ulcer disease: A common cause of upper gastrointestinal bleeding, which should be ruled out before considering Dieulafoy's lesion [8].
• Esophageal varices: Enlarged veins in the esophagus that can cause bleeding.
• Enteric angiodysplasia: A condition characterized by vascular malformations in the small intestine.

Key Considerations

• Age, comorbidities, and overall health of the patient should be taken into account when considering differential diagnoses [10].
• Angiography can help differentiate between Dieulafoy's lesion and other vascular malformations.
• A thorough endoscopic examination is essential to rule out other causes of upper gastrointestinal bleeding.

References

[1] Baxter M. (2010) - Dieulafoy's lesion should be included in the differential diagnosis of obscure GI bleeding in all age groups [3]. [10] Salimi J. (2021) - In conclusion, we recommend that DL should be considered as an important differential diagnosis in acute and chronic GI bleeding [7]. [8] Chaudrey K. (2010) - Their differential diagnosis includes enteric angiodysplasia, telangiectasias, venous ectasia, hemangioma and an A-V malformation [9].