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World J Gastrointest Endosc. Apr 16, 2015; 7(4): 295-307
Published online Apr 16, 2015. doi: 10.4253/wjge.v7.i4.295
Gastrointestinal bleeding from Dieulafoy’s lesion: Clinical presentation, endoscopic findings, and endoscopic therapy
Borko Nojkov, Mitchell S Cappell
Borko Nojkov, Mitchell S Cappell, Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
Borko Nojkov, Mitchell S Cappell, Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, United States
Author contributions: Both authors ontributed equally to this work.
Conflict-of-interest: None for all authors. This paper does not discuss any confidential pharmaceutical data reviewed by Dr. Cappell as a consultant for the United States Food and Drug Administration Advisory Committee on Gastrointestinal Drugs.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Mitchell S Cappell, MD, PhD, Division of Gastroenterology and Hepatology, William Beaumont Hospital, MOB 602, 3535 W. Thirteen Mile Road, Royal Oak, MI 48073, United States. mscappell@yahoo.com
Telephone: +1-248-5511227 Fax: +1-248-5515010
Received: October 29, 2014
Peer-review started: November 2, 2014
First decision: December 12, 2014
Revised: December 20, 2014
Accepted: January 9, 2015
Article in press: January 12, 2015
Published online: April 16, 2015
Processing time: 172 Days and 8.5 Hours
Abstract

Although relatively uncommon, Dieulafoy’s lesion is an important cause of acute gastrointestinal bleeding due to the frequent difficulty in its diagnosis; its tendency to cause severe, life-threatening, recurrent gastrointestinal bleeding; and its amenability to life-saving endoscopic therapy. Unlike normal vessels of the gastrointestinal tract which become progressively smaller in caliber peripherally, Dieulafoy’s lesions maintain a large caliber despite their peripheral, submucosal, location within gastrointestinal wall. Dieulafoy’s lesions typically present with severe, active, gastrointestinal bleeding, without prior symptoms; often cause hemodynamic instability and often require transfusion of multiple units of packed erythrocytes. About 75% of lesions are located in the stomach, with a marked proclivity of lesions within 6 cm of the gastroesophageal junction along the gastric lesser curve, but lesions can also occur in the duodenum and esophagus. Lesions in the jejunoileum or colorectum have been increasingly reported. Endoscopy is the first diagnostic test, but has only a 70% diagnostic yield because the lesions are frequently small and inconspicuous. Lesions typically appear at endoscopy as pigmented protuberances from exposed vessel stumps, with minimal surrounding erosion and no ulceration (visible vessel sans ulcer). Endoscopic therapy, including clips, sclerotherapy, argon plasma coagulation, thermocoagulation, or electrocoagulation, is the recommended initial therapy, with primary hemostasis achieved in nearly 90% of cases. Dual endoscopic therapy of epinephrine injection followed by ablative or mechanical therapy appears to be effective. Although banding is reportedly highly successful, it entails a small risk of gastrointestinal perforation from banding deep mural tissue. Therapeutic alternatives after failed endoscopic therapy include repeat endoscopic therapy, angiography, or surgical wedge resection. The mortality has declined from about 30% during the 1970’s to 9%-13% currently with the advent of aggressive endoscopic therapy.

Keywords: Dieulafoy’s lesion; Gastrointestinal bleeding

Core tip: Dieulafoy’s lesion is an important cause of acute gastrointestinal bleeding. Dieulafoy’s lesions maintain an abnormally large caliber despite their peripheral, submucosal, location. Dieulafoy’s lesions typically present with severe, active, gastrointestinal bleeding. About 75% of lesions are located in the stomach, most commonly close to the gastroesophageal junction, but lesions can occur in duodenum and esophagus. Endoscopy is the first diagnostic test (70% diagnostic yield). Lesions typically appear at endoscopy as pigmented protuberances from exposed vessel stumps, with minimal surrounding erosions. Endoscopic therapy, including clips, sclerotherapy, argon plasma coagulation, thermocoagulation, or electrocoagulation, is the recommended initial therapy, with primary hemostasis achieved in nearly 90% of cases. Mortality of bleeding from this lesion is 9%-13%.