Gastrointestinal bleeding from Dieulafoy’s lesion: Clinical presentation, endoscopic findings, and endoscopic therapy

Table 1 Clinico-epidemiologic characteristics of Dieulafoy lesion

Anatomy

Dilated, aberrant, submucosal artery eroding overlying gastrointestinal mucosa in absence of either underlying ulcer or local aneurysm

Location

70% of ulcers in stomach

In stomach most commonly located within 6 cm of gastroesophageal junction along lesser curve

Can occur moderately commonly in esophagus or duodenum, occasionally in jejunum or ileum, and rarely in colon

Epidemiology

Generally presents clinically in older age, but can occur at any age

Male:female ratio = 2:1

No known epidemiologic risk factors or clinically associated diseases

Clinical presentation

Typically presents with overt GI bleeding, often with hematemesis or melena, or both

Bleeding typically severe

No prodromal symptoms

Typically bleeding is painless

Frequent presentation with signs or laboratory tests of hemodynamic instability, including: tachycardia, hypotension, orthostasis, and acute prerenal azotemia

Frequently requires transfusion of multiple units of packed erythrocytes

Frequent recurrent bleeding if undetected or not treated at initial endoscopy

GI: Gastrointestinal.

Table 2 Diagnosis of Dieulafoy’s lesion

EGD

Small, relatively inconspicuous pigmented protuberance with minimal surrounding erosion and no ulceration

Lesion often actively bleeding or oozing at EGD

Gastric lesions most commonly within 6 cm of GE junction along lesser curve

Initial EGD may be nondiagnostic in up to 30% of cases due to relatively small lesion size

Avoid endoscopic biopsies of lesion

Colonoscopy or enteroscopy

May be useful to diagnose colonic or jejunoileal lesions, respectively, if EGD was negative in setting of severe, acute GI bleeding

Angiography

May be helpful in setting of rectal bleeding after negative EGD and colonoscopy

EGD: Esophagogastroduodenoscopy; GI: Gastrointestinal.

Table 3 Therapy for Dieulafoy’s lesion

Pre-endoscopic therapy

Secure IV access using multiple, large bore catheters

Volume resuscitation initially using crystalloid followed by transfusions of packed erythrocytes as dictated by serial hematocrit determinations and tempo of bleeding

Endoscopic therapies

Mechanical therapies

Hemoclips

Band ligation

Injection therapies

Epinephrine injection

Absolute alcohol

Ablative therapies

Heater probe

Electrocoagulation: Bicap, gold probe, etc.,

APC (argon plasma coagulation)

Combination therapies

Usually epinephrine injection therapy followed by:

Heater probe

Hemoclip

Or APC

Interventional angiography

Embolization

Pledgelets

Metal coils

Balloon occlusion

Surgery

Mostly salvage therapy after failure of other interventional therapies

APC: Argon plasma coagulation.

Table 4 Efficacy of endoscopic mechanical monotherapies for bleeding Dieulafoy’s lesions

Endoscopic procedure(No. of patients)	Lesion location	Type of study	Follow-up	Outcome	Ref.
Hemoclips
EGD (34)	Stomach/duodenum	Prospective	54 mo	initial hemostasis 32/34 pts (94%), 3 pts (9%) rebled	[75]
EGD (18)	Stomach	Retrospective	36 mo	1 (5%) rebled	[77]
EGD (16)	Stomach/duodenum	Prospective, randomized	1 wk	1 (6%) rebled	[78]
Mostly EGD (14)	Mostly stomach/duodenum	Retrospective	Hospitalization	No rebleeding	[36]
EGD (8) Colonoscopy (1)	Stomach Rectum	Retrospective	19 mo	1 (12%) rebled	[73]
EGD (6)	Stomach/duodenum	Retrospective	47 mo	1 (17%) rebled, unclear if single/combination therapy	[79]
Colonoscopy (3)	Rectum	Retrospective	5 mo	No rebleeding	[80]
Double balloon enteroscopy (3)	Jejunum	Retrospective, multicenter	14.5 mo	1 (33%) rebled 69 d after hemoclip	[17]
Single balloon enteroscopy (2)	Ileum	Retrospective	2 mo	No rebleeding	[18]
Colonoscopy (1)	Colon	Case report	6 mo	No rebleeding	[33]
Band ligation
EGD (24)	Stomach 23 Jejunum 1	Retrospective	18 mo	1 (4%) hemostasis failure, 1 (4%) rebled (jejunum)	[81]
EGD (13)	Stomach Esophagus	Prospective	24 wk	No rebleeding	[82]
EGD (13)	Stomach/duodenum	Retrospective	30 d	No rebleeding	[83]
EGD (10)	Stomach	Prospective	30 d	No rebleeding	[76]
EGD (7)	Stomach	Retrospective	8 mo	No rebleeding	[84]
EGD (3)	Upper GI	Retrospective	19 mo	No rebleeding	[73]
“Mostly” EGD (2)	Stomach	Retrospective	Hospitalization	No rebleeding	[75]
EGD (1)	Stomach	Retrospective	2 d	No rebleeding	[35]
Colonoscopy (4)	Rectum	Retrospective	2-5 d	2 (50%) rebled	[85]
Colonoscopy (3)	Rectum	Retrospective	5 mo	No rebleeding	[80]

Pts: Patients; EGD: Esophagogastroduodenoscopy; GI: Gastrointestinal.

Table 5 Efficacy of endoscopic injection monotherapy for bleeding Dieulafoy’s lesions

Endoscopic procedure(No. of patients)	Lesion location	Type of study	Follow-up	Outcome	Ref.
Epinephrine injection
EGD (16)	Stomach/duodenum	Prospective	1 wk	2 (12%) hemostasis failure, 5 (31%) rebled	[78]
EGD (11) Colonoscopy (1)	Stomach Rectum	Retrospective	22 mo	3 (27%) hemostasis failure, 4 (36%) rebled	[73]
EGD (11)	Stomach/duodenum	Retrospective	18 mo	3 (27%) hemostasis failure, 2 (18%) rebled	[88]
“Mostly” EGD (8)	Mostly stomach/duodenum	Retrospective	Hospitalization	No rebleeding	[36]
EGD (8)	Stomach	Prospective	30 d	6 (75%) rebled	[76]
EGD (6)	Stomach	Retrospective	60 d	2 (33%) hemostasis failure	[40]
EGD (3) Colonoscopy (1)	Stomach/duodenum cecum (1)	Retrospective	14 mo	No rebleeding	[35]
EGD (3)	Stomach	Retrospective	32 mo	2 (66%) rebled	[72]
Absolute ethanol injection
EGD (12)	Stomach/duodenum	Retrospective	69 mo	1 (8%) hemostasis failure, no rebleeding	[89]
Ethanolamine injection
EGD (1)	Stomach	Retrospective	8 mo	Rebled	[72]

EGD: Esophagogastroduodenoscopy.

Table 6 Effectiveness of endoscopic ablation monotherapies for bleeding Dieulafoy’s lesions

Endoscopic procedure(No. of patients)	Lesion location	Type of study	Follow-up	Outcome	Ref.
Heater probe coagulation
EGD (6)	Stomach/duodenum	Retrospective	14 mo (2/3 of pts)	No rebleeding	[35]
EGD (6)	Stomach	Retrospective	36 mo	2 (33%) rebled	[77]
Mostly EGD (5)	Mostly stomach/duodenum	Retrospective	Hospitalization	No rebleeding	[36]
EGD (1)	Stomach	Retrospective	40 mo	No rebleeding	[72]
Argon plasma coagulation
Double balloon enteroscopy (3)	Jejunum-2, Ileum-1	Retrospective /multicenter	14 mo	1 (33%) rebled	[17]
EGD (3)	Stomach	Retrospective	2 mo	No rebleeding	[40]
EGD (1)	Likely upper GI	Retrospective	Hospitalization	No rebleeding	[36]
Multipolar electrocoagulation
EGD (14)	Stomach	Retrospective	24 mo	1 (7%) hemostasis failure, 1 rebled	[82]
EGD (1)	Likely upper GI	Retrospective	Hospitalization	Rebled	[36]

Table 7 Effectiveness of various combination endoscopic therapies for bleeding Dieulafoy’s lesions

Endoscopic therapies (No. of patients)	Endoscopy: lesion location	Type of study	Mean length of follow-up	Study outcome	Ref.
Epinephrine and polidocanol (27)	EGD: stomach/duodenum	Retrospective	28 mo	5 (18%) rebled	[71]
Epi and heater probe (28)	EGD: stomach/duodenum	Retrospective	14 mo (2/3 of patients)	2 (7%) rebled	[35]
Epi and heater probe (10)	EGD: stomach/duodenum	Retrospective	18 mo	No rebleeding	[88]
Epi and heater probe (9)	“Mostly” EGD; Mostly stomach/duodenum	Retrospective	Hospitalization	1 (11%) rebled	[36]
Epi and heater probe (8)	EGD: stomach/duodenum	Retrospective	32 mo	No rebleeding	[72]
Epi and heater probe (6)	EGD	Retrospective	2 mo	No rebleeding	[40]
Epi and heater probe (2)	Colonoscopy	Retrospective	1 and 7 mo	No rebleeding	[59]
Epi and hemoclip and ethanol injection (21)	EGD: stomach/duodenum	Retrospective	47 mo	1 (4%) rebled	[79]
Epi and hemoclip (19)	EGD: Stomach	Retrospective	47 mo	1 (5%) rebled	[79]
Epi and hemoclip (16)	“Mostly” EGD: mostly stomach/ duodenum	Retrospective	During hospitalization	1 (6%) rebled	[36]
Epi and hemoclip (3)	EGD: Stomach	Retrospective	2 mo	No rebleeding	[40]
Epi and multipolar electrocoagulation (5)	“Mostly” EGD: Mostly stomach/duodenum	Retrospective	During hospitalization	1 (20%) rebled	[36]
Epi and banding (1)	EGD: stomach	Retrospective	During hospitalization	No rebleeding	[36]
Epi and ethanol (52)	EGD: Stomach/ duodenum	Retrospective	69 mo	Approximately 9% hemostasis failure, 10 (20%) rebled	[89]
Epi and ethanol (11)	EGD: stomach duodenum	Retrospective	47 mo	1 rebled	[79]
Epi and ethanolamine (5)	EGD: stomach/duodenum	Retrospective	32 mo	2 (40%) rebled	[72]
Injection therapy and clip (2)	Double balloon enteroscopy: jejunum	Retrospective, multicenter	14 mo	No rebleeding	[17]
Injection therapy and APC (1)	Double balloon enteroscopy: jejunum	Retrospective, multicenter	14 mo	Rebled after 9 d	[17]
Injection and heater probe and clips (1)	Colonoscopy: colon	Case report	NA	No rebleeding	[90]

Epi: Epinephrine; APC: Argon plasma coagulation; NA: Not available.