1
|
Ouyang Q, Xia Y, Wang L, Qiu J, Zhang Y, Ding R, Zhu Z, Shu X, Pan X. The efficacy of sclerotherapy as the initial treatment in patients with bleeding from Dieulafoy's lesion of the upper gastrointestinal tract. Surg Endosc 2024; 38:3773-3782. [PMID: 38789624 DOI: 10.1007/s00464-024-10854-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 04/10/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Dieulafoy's lesion (DL) is a rare and important cause of acute nonvariceal upper gastrointestinal bleeding (ANVUGIB), however, there is a lack of clear guidelines focus on the endoscopic hemostasis treatment for DL. Sclerotherapy, as the ANVUGIB guideline recommended endoscopic hemostasis method, is widely used in clinical practice. The aim of this study is to investigate the efficacy of sclerotherapy as the initial treatment for Dieulafoy's lesion of the upper gastrointestinal tract (UDL). METHODS Patients with UDL who underwent the ANVUGIB standard endoscopic hemostasis between April 2007 and January 2023 were enrolled. The endoscopic therapy method was left to the discretion of the endoscopist. RESULTS In total, 219 patients were finally obtained, with 74 (33.8%) receiving sclerotherapy and 145 (66.2%) receiving other standard endoscopic therapy. The rebleeding within 30 days was significantly lower in the sclerotherapy group compared to the other standard group (5.8% vs. 16.8%, p = 0.047). There were no significant differences between the two groups in terms of successful hemostasis rate (93.2% vs. 94.5%, p = 0.713), median number of red blood cell transfusions (3.5 vs. 4.0 units, p = 0.257), median hospital stay (8.0 vs. 8.0 days, p = 0.103), transferred to ICU rate (8.1% vs. 6.2%, p = 0.598), the need for embolization or surgery rate (12.2% vs. 9.7%, p = 0.567) and 30-day mortality (0 vs. 2.1%, p = 0.553). In addition, we found no difference in efficacy between sclerotherapy alone and combination (3.1% vs. 8.1%, p = 0.714). Further analysis revealed that thermocoagulation for hemostasis was associated with a higher rate of rebleeding (28.6% vs. 3.1%, p = 0.042) and longer hospital stay (11.5 vs. 7.5 days, p = 0.005) compared to sclerotherapy alone. CONCLUSION Sclerotherapy represents an effective endoscopic therapy for both alone and combined use in patients with upper gastrointestinal Dieulafoy's lesion. Therefore, sclerotherapy could be considered as initial treatment in patients with bleeding of UDL.
Collapse
Affiliation(s)
- Qingping Ouyang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Yanhong Xia
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Liping Wang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Jiayu Qiu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Yanxia Zhang
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Ruiying Ding
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Zhenhua Zhu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Xu Shu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
| | - Xiaolin Pan
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
| |
Collapse
|
2
|
Hu Q, Guo Y, Fan H, Wu X, Chen H, Zeng C. Pathological features of vascular wall in Dieulafoy's disease. Pathol Res Pract 2023; 249:154782. [PMID: 37639956 DOI: 10.1016/j.prp.2023.154782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/25/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
AIMS Although there are many clinical reports on Dieulafoy's disease, there are few studies on the pathological structure of vascular wall in Dieulafoy's disease. METHODS In this study, the main structural changes of the intima and media of the vascular wall were observed by special staining and immunohistochemical methods in the subjects of Dieulafoy's disease of stomach and intestine. RESULTS There were many vessels of different sizes in the submucosa, with uneven wall thickness of the vessels. Compared with the normal control group, the content of blue collagen fibers between the vascular smooth muscle cells in the lesion group was increased, the elastic fibers were thickened, and the internal elastic plate was arranged stiff or even interrupted. CONCLUSIONS The increase of collagen and elastic fibers between the smooth muscle cells of the medium membrane and the destruction of the structure of the inner elastic plate may be the structural basis of vascular lesions leading to Dieulafoy's disease.
Collapse
Affiliation(s)
- Qiaoling Hu
- Department of Pathology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong 518033, PR China
| | - Yimin Guo
- Department of Pathology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong 518033, PR China
| | - Huan Fan
- Department of Pathology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong 518033, PR China
| | - Xiaobin Wu
- Department of Gastrointestinal Surgery, The Eighth Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong 518033, PR China.
| | - Honglei Chen
- Gastrointestinal Endoscopy Center, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong 518033, PR China.
| | - Chao Zeng
- Department of Pathology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong 518033, PR China.
| |
Collapse
|
3
|
AL-Busaidi A, Alomairi J, Alabri O, Alwheibi E, Almaghadari A, Kadom MR, O'Connell PR. Upper gastrointestinal bleeding due to Dieulafoy's lesion of the stomach: a rare case report. EXCLI JOURNAL 2023; 22:862-866. [PMID: 37780938 PMCID: PMC10539546 DOI: 10.17179/excli2023-6407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/08/2023] [Indexed: 10/03/2023]
Abstract
Dieulafoy's lesion is a life-threatening and rare vascular malformation of the submucosal vessel that protrudes to the mucosa of the gastrointestinal tract. The vessel is abnormally dilated, and if it ruptures, it can cause severe acute gastrointestinal bleeding. We report an upper GI bleeding case due to Dieulafoy's lesion in the gastric fundus of the stomach in a 76-year-old female. The patient presented with hematemesis and melena associated with anemia. An esophagogastroduodenoscopy (OGD) was performed which showed profuse pulsatile bleeding at the gastric fundus. Following that, gastrotomy confirmed the diagnosis of Dieulafoy's lesion. Endoscopy is the main diagnostic and therapeutic tool for Dieulafoy's lesion. Endoscopic treatment includes injective, ablative and mechanical therapies. The majority of cases are treated endoscopically, while in some cases, surgical intervention is deemed to be necessary as it is currently the only definitive treatment of Dieulafoy's lesion.
Collapse
Affiliation(s)
- Alsalt AL-Busaidi
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Jaifar Alomairi
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Omer Alabri
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Eissa Alwheibi
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | | | - Mhmod R. Kadom
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | | |
Collapse
|
4
|
Demetiou G, Augoustaki A, Kalaitzakis E. Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review. World J Gastrointest Endosc 2022. [DOI: 10.4253/wjge.v14.i3.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
5
|
Demetriou G, Augoustaki A, Kalaitzakis E. Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review. World J Gastrointest Endosc 2022; 14:163-175. [PMID: 35432740 PMCID: PMC8984531 DOI: 10.4253/wjge.v14.i3.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/08/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute non-variceal bleeding accounts for approximately 20% of all-cause bleeding episodes in patients with liver cirrhosis. It is associated with high morbidity and mortality therefore prompt diagnosis and endoscopic management are crucial.
AIM To evaluate available data on the efficacy of endoscopic treatment modalities used to control acute non-variceal gastrointestinal bleeding (GIB) in cirrhotic patients as well as to assess treatment outcomes.
METHODS Employing PRISMA methodology, the MEDLINE was searched through PubMed using appropriate MeSH terms. Data are reported in a summative manner and separately for each major non-variceal cause of bleeding.
RESULTS Overall, 23 studies were identified with a total of 1288 cirrhotic patients of whom 958/1288 underwent endoscopic therapy for acute non-variceal GIB. Peptic ulcer bleeding was the most common cause of acute non-variceal bleeding, followed by portal hypertensive gastropathy, gastric antral vascular ectasia, Mallory-Weiss syndrome, Dieaulafoy lesions, portal hypertensive colopathy, and hemorrhoids. Failure to control bleeding from all-causes of non-variceal GIB accounted for less than 3.5% of cirrhotic patients. Rebleeding (range 2%-25%) and mortality (range 3%-40%) rates varied, presumably due to study heterogeneity. Rebleeding was usually managed endoscopically and salvage therapy using arterial embolisation or surgery was undertaken in very few cases. Mortality was usually associated with liver function deterioration and other organ failure or infections rather than uncontrolled bleeding. Endoscopic treatment-related complications were extremely rare. Lower acute non-variceal bleeding was examined in two studies (197/1288 patients) achieving initial hemostasis in all patients using argon plasma coagulation for portal hypertensive colopathy and endoscopic band ligation or sclerotherapy for bleeding hemorrhoids (rebleeding range 10%-13%). Data on the efficacy of endoscopic therapy of cirrhotic patients vs non-cirrhotic controls with acute GIB are very scarce.
CONCLUSION Endotherapy seems to be efficient as a means to control non-variceal hemorrhage in cirrhosis, although published data are very limited, particularly those comparing cirrhotics with non-cirrhotics and those regarding acute bleeding from the lower gastrointestinal tract. Rebleeding and mortality rates appear to be relatively high, although firm conclusions may not be drawn due to study heterogeneity. Hopefully this review may stimulate further research on this subject and help clinicians administer optimal endoscopic therapy for cirrhotic patients.
Collapse
Affiliation(s)
- Georgios Demetriou
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| | - Aikaterini Augoustaki
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| | - Evangelos Kalaitzakis
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| |
Collapse
|
6
|
Onmez A, Torun S. Use of Over-the-Scope Clip as First Choice to Treat Gastric Dieulafoy Lesions. Middle East J Dig Dis 2021; 13:163-165. [PMID: 34712456 PMCID: PMC8531925 DOI: 10.34172/mejdd.2021.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/04/2020] [Indexed: 11/09/2022] Open
Abstract
Dieulafoy lesion is a rarely seen, superficial vascular lesion of the gastric mucosa that can lead to severe and recurrent bleeding which can be life-threatening. It is characterized by massive hemorrhages that can occur as a result of protrusion of a large artery from a submucosal defect. Endoscopic injection and mechanical and thermal methods are frequently used in traditional treatment. Herein, we presented a 61-year-old women who was admitted with upper gastrointestinal hemorrhage owing to Dieulafoy lesion who was successfully treated with over-the-scope clip as the first choice of treatment.
Collapse
Affiliation(s)
- Attila Onmez
- Assistant Professor, Department of Internal Medicine, Duzce University Medical Faculty, Duzce, Turkey
| | - Serkan Torun
- Associate Professor, Department of Gastroenterology, Duzce University Medical Faculty, Duzce, Turkey
| |
Collapse
|
7
|
Wang Y, Bansal P, Li S, Iqbal Z, Cheryala M, Abougergi MS. Dieulafoy's lesion of the upper GI tract: a comprehensive nationwide database analysis. Gastrointest Endosc 2021; 94:24-34.e5. [PMID: 33359438 DOI: 10.1016/j.gie.2020.12.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/03/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS We sought to determine the incidence, risk factors, and treatment outcomes of Dieulafoy's lesion of the upper GI tract (UDL) hemorrhage among adult patients in the United States. METHODS UDL and non-Dieulafoy upper GI bleeding (UGIB) were identified from the Nationwide Inpatient Sample and Nationwide Readmission Database using International Classification of Diseases, Tenth Revision, Clinical Modification and Procedure Coding System codes. Multivariate logistic (binary) and linear (continuous) regressions were used to model dependent variables. RESULTS The incidence of UDL hemorrhage was 1.6 of 100,000 persons. Patients with UDL and UGIB who required endoscopic therapeutic intervention had similar in-hospital (adjusted odds ratio [aOR], .77; 95% confidence interval [CI], .42-1.43; P = .41) mortality rates. UDL was associated with more severe systemic illness, including higher rates of mechanical ventilation (aOR, 1.52; 95% CI, 1.07-2.15; P < .05), hypovolemic shock (aOR, 1.50; 95% CI, 1.08-2.08; P < .05), acute kidney injury (aOR, 1.25; 95% CI, 1.02-1.54; P < .05), and multiple endoscopies (aOR, 1.57; 95% CI, 1.28-1.93; P < .05) compared with other UGIB patients who required endoscopic therapeutic intervention. UDL was also associated with higher 30-day all-cause (aOR, 1.23; 95% CI, 1.12-1.35; P < .05) and recurrent bleeding-related (aOR, 1.73; 95% CI, 1.45-2.06; P < .05) readmissions. The rate of successful endoscopic treatment was 96.81%. CONCLUSIONS UDL hemorrhage is an uncommon but highly morbid condition. Current UDL treatment modalities are effective in reducing mortality. Further investigations are warranted to lower recurrent bleeding rates.
Collapse
Affiliation(s)
- Yichen Wang
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Pardeep Bansal
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA; Division of Gastroenterology, Regional Hospital and Moses Taylor Hospital, Scranton, Pennsylvania, USA
| | - Si Li
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Zaid Iqbal
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Mahesh Cheryala
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Marwan S Abougergi
- Catalyst Medical Consulting, Simpsonville, South Carolina, USA; Division of Gastroenterology, Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA
| |
Collapse
|
8
|
First Case of Laparoscopic-Endoscopic Management of a Rare Complication After Roux-en-Y Gastric Bypass: Bleeding Dieulafoy's Lesion in the Excluded Duodenal Tract. Obes Surg 2021; 31:3866-3868. [PMID: 33871772 DOI: 10.1007/s11695-021-05432-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 12/26/2022]
|
9
|
Malik A, Inayat F, Goraya MHN, Almas T, Ishtiaq R, Malik S, Tarar ZI. Jejunal Dieulafoy's Lesion: A Systematic Review of Evaluation, Diagnosis, and Management. J Investig Med High Impact Case Rep 2021; 9:2324709620987703. [PMID: 33472441 PMCID: PMC7829607 DOI: 10.1177/2324709620987703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/10/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022] Open
Abstract
Jejunal Dieulafoy's lesion is an exceedingly rare but important cause of gastrointestinal bleeding. It frequently presents as a diagnostic and therapeutic conundrum due to the rare occurrence, intermittent bleeding symptoms often requiring prompt clinical action, variability in the detection and treatment methods, and the risk of rebleeding. We performed a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases regarding jejunal Dieulafoy's lesio from inception till June 2020. A total of 136 cases were retrieved from 76 articles. The mean age was 55 ± 24 years, with 55% of cases reported in males. Patients commonly presented with melena (33%), obscure-overt gastrointestinal bleeding (29%), and hemodynamic compromise (20%). Hypertension (26%), prior gastrointestinal surgery (14%), and valvular heart disease (13%) were the major underlying disorders. Conventional endoscopy often failed but single- and double-balloon enteroscopy identified the lesion in 96% and 98% of patients, respectively. There was no consensus on the treatment. Endoscopic therapy was instituted in 64% of patients. Combination therapy (34%) with two or more endoscopic modalities, was the preferred approach. With regard to endoscopic monotherapy, hemoclipping (19%) and argon plasma coagulation (4%) were frequently employed procedures. Furthermore, direct surgical intervention in 32% and angiographic embolization was performed in 4% of patients. The rebleeding rate was 13.4%, with a mean follow-up duration of 17.6 ± 21.98 months. The overall mortality rate was 4.4%. Jejunal Dieulafoy's lesion is still difficult to diagnose and manage. Although the standard diagnostic and therapeutic modalities remain to be determined, device-assisted enteroscopy might yield promising outcomes.
Collapse
Affiliation(s)
- Adnan Malik
- Loyola University Medical Center,
Maywood, IL, USA
| | - Faisal Inayat
- Allama Iqbal Medical College, Lahore,
Punjab, Pakistan
| | | | - Talal Almas
- Royal College of Surgeons in Ireland,
Dublin, Ireland
| | | | - Sohira Malik
- Nishter Medical University, Multan,
Punjab, Pakistan
| | | |
Collapse
|
10
|
Hagen M, Varchmin-Schultheiss K. Tödliches Dieulafoy-Ulkus. Rechtsmedizin (Berl) 2020. [DOI: 10.1007/s00194-020-00435-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
ZusammenfassungNach einem Schlaganfall wurde ein 51 Jahre alter Mann in eine Rehaklinik verlegt. Gemäß klinischen Angaben soll sich dort eine Sepsis entwickelt haben. Aufgrund eines plötzlichen Bewusstseinsverlustes wurde der Patient umgehend in die nächstgelegene Klinik verbracht, wo er trotz umgehender Behandlung verstarb. Da die Ehefrau Vorwürfe gegen das Personal der Rehaklinik erhob, wurde eine rechtsmedizinische Obduktion in Auftrag gegeben.Im Rahmen der Obduktion fielen große Mengen flüssigen Blutes im Magen sowie im oberen Gastrointestinaltrakt auf, sodass bereits autoptisch ein inneres Verbluten als Todesursache definiert wurde. Als Blutungsquelle kam ein makromorphologisch auffälliges, eröffnetes Gefäß im Magenfundus in Betracht. Die sichere Diagnose eines tödlichen Dieulafoy-Ulkus konnte jedoch erst nach histologischer Begutachtung erfolgen. Definierend für diesen Befund ist eine kaliberpersistente Arterie in der Submukosa ohne pathologische Veränderungen. Bei sicherer Diagnose kann dieser Befund einen plötzlichen Tod aus natürlicher Ursache darstellen. Da das Ulkus im gesamten gastrointestinalen Trakt vorkommen kann, ist bei relevantem Blutverlust und unklarer Blutungsquelle neben der genauen Inspektion eine histologische Aufarbeitung möglicher Blutungsquellen unerlässlich. Damit die Kriterien eines Dieulafoy-Ulkus beurteilt werden können, sollte neben einer HE(Hämatoxylin-Eosin)-Färbung mindestens eine EvG(Elastica-van-Gieson)-Färbung durchgeführt werden. Nur dann können alternative Entstehungsmöglichkeiten ausgeschlossen werden, welche aus forensischer Sicht möglicherweise hätten verhindert werden können.
Collapse
|
11
|
Chakinala RC, Solanki S, Haq KF, Singh J, Shah H, Solanki D, Kichloo A, Haq KS, Burney AH, Waqar S, Vyas M, Chugh S, Nabors C. Dieulafoy's Lesion: Decade-Long Trends in Hospitalizations, Demographic Disparity, and Outcomes. Cureus 2020; 12:e9170. [PMID: 32802607 PMCID: PMC7424366 DOI: 10.7759/cureus.9170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Dieulafoy's lesion is a relatively rare, but potentially life-threatening, condition where a tortuous arteriole, most commonly in the stomach, may bleed and lead to significant gastrointestinal hemorrhage. Limited epidemiological data exist on patient characteristics and the annual number of hospitalizations associated with such lesions. The aim of our study is to determine the inpatient burden of Dieulafoy’s lesion. Methods We analyzed the National Inpatient Sample (NIS) database for all subjects with a discharge diagnosis of Dieulafoy's lesion of the stomach, duodenum, and colon using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 537.84 and 569.86 as the primary or secondary diagnosis during the period from 2002 to 2011. Statistical significance of variation in the number of hospital discharges and demographics during the study period was achieved using the Cochrane-Armitage trend test. Results In 2002, there were 1,071 admissions with a discharge diagnosis of Dieulafoy's lesion as compared to 7,414 in 2011 (p < 0.0001). Dieulafoy's lesion was found to be most common in the age group of 65-79 years (p < 0.0001). Overall, it was found to be more common in males as compared to females (p = 0.0261). The white race was most commonly affected amongst all the races. The average cost of care per hospitalization increased from $14,992 in 2002 to $25,594 in 2011 (p < 0.0001). Conclusion There has been a steady rise in the number of inpatient admissions with Dieulafoy's lesions. Advances in diagnostic techniques likely play a key role in the higher detection rates along with the possible involvement of other unknown factors. Men, in the age group of 65 to 79 years, and Whites were found to have significantly higher admission rates than all other groups, with a significant increase in the cost of care.
Collapse
Affiliation(s)
| | - Shantanu Solanki
- Hospital-Based Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
| | - Khwaja F Haq
- Gastroenterology, Henry Ford Hospital, Detroit, USA
| | - Jagmeet Singh
- Nephrology, Geisinger Commonwealth School of Medicine, Scranton, USA
| | - Harshil Shah
- Internal Medicine, Independent Researcher, Sayre, USA
| | | | - Asim Kichloo
- Internal Medicine, Central Michigan University, Saginaw, USA
| | - Khwaja S Haq
- Medicine, Kingsbrook Jewish Medical Center, Brooklyn, USA
| | - Azam H Burney
- Medicine, Kingsbrook Jewish Medical Center, Brooklyn, USA
| | | | - Manasee Vyas
- Medicine, Mahatma Gandhi Institute of Health Sciences, Mumbai, IND
| | - Savneek Chugh
- Nephrology, Westchester Medical Center, Valhalla, USA
| | | |
Collapse
|
12
|
Abstract
Dieulafoy's lesion is a histologically normal arteriole that has failed to progressively narrow as it navigates through the submucosa. It is a rare cause of massive gastrointestinal bleeding, occurring most often in the stomach, with only 1% of lesions occurring in the jejunum. We present the case of a 21-year-old man who presented with massive hematochezia ultimately attributed to a distal jejunal Dieulafoy's lesion, identified via an intraoperative surgically assisted deep enteroscopy. This case is unique not only regarding the unusual location of the lesion but also regarding the multidisciplinary approach necessitated for the management of this catastrophic hemorrhage that avoided surgical resection.
Collapse
|
13
|
Abstract
Despite modern investigative innovations in the cutting edge field of gastroenterology, we are reminded of our contemporary limitations when we encounter the ever evasive Dieulafoy’s lesion (DL). Ever since it has been initially described in 1884, its rare but frustrating presence creates a calamitous situation. Even more so when it presents atypically, much like it did in our patient. This review of DL delves into the history, epidemiology, characteristics, the most current and innovative diagnostic measures available, as well as treatment and prevention of recurrence of these obscure gastrointestinal (GI) bleeding sources.
Collapse
Affiliation(s)
- Sindhura Kolli
- Internal Medicine, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, USA
| | - Khoi Paul Dang-Ho
- Internal Medicine, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, USA
| | - Amit Mori
- Gastroenterology, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, USA
| | - Krishna Gurram
- Gastroenterology, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, USA
| |
Collapse
|
14
|
Then EO, Bijjam R, Ofosu A, Rawla P, Culliford A, Gaduputi V. Rectal Dieulafoy's Lesion: A Rare Etiology of Lower Gastrointestinal Hemorrhage. Case Rep Gastroenterol 2019; 13:73-77. [PMID: 31043932 PMCID: PMC6477460 DOI: 10.1159/000497139] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/21/2019] [Indexed: 12/19/2022] Open
Abstract
A Dieulafoy's lesion is defined as a dilated submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. It is a rare cause of gastrointestinal bleeding that is difficult to identify and subsequently manage. Most commonly, they occur in the upper gastrointestinal tract, namely the stomach. A Dieulafoy's lesion of the rectum, however, is an exceedingly rare presentation that can lead to life-threatening gastrointestinal bleeding. Our case consists of an 84-year-old man, who presented with lower gastrointestinal bleeding secondary to a Dieulafoy's lesion of the rectum.
Collapse
Affiliation(s)
- Eric Omar Then
- Division of Gastroenterology and Hepatology, SBH Health System, Bronx, New York, USA
| | - Rani Bijjam
- Division of Gastroenterology and Hepatology, SBH Health System, Bronx, New York, USA
| | - Andrew Ofosu
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn, New York, USA
| | - Prashanth Rawla
- Department of Internal Medicine, Memorial Hospital of Martinsville and Henry County, Martinsville, Virginia, USA
| | - Andrea Culliford
- Division of Gastroenterology and Hepatology, SBH Health System, Bronx, New York, USA
| | - Vinaya Gaduputi
- Division of Gastroenterology and Hepatology, SBH Health System, Bronx, New York, USA
| |
Collapse
|
15
|
Successful endovascular treatment of a 13-month-old child with gastrointestinal bleeding due to Dieulafoy syndrome of duodenum. Radiol Case Rep 2018; 13:685-688. [PMID: 29682140 PMCID: PMC5909029 DOI: 10.1016/j.radcr.2018.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 03/16/2018] [Indexed: 11/21/2022] Open
Abstract
Dieulafoy disease can manifest itself with spontaneous massive recurrent gastrointestinal bleeding in children. We report a case of successful management of a 13-month-old child with Dieulafoy disease of duodenum when traditional methods of examination and treatment failed.
Collapse
|
16
|
Inayat F, Amjad W, Hussain Q, Hurairah A. Dieulafoy's lesion of the duodenum: a comparative review of 37 cases. BMJ Case Rep 2018; 2018:bcr-2017-223246. [PMID: 29472423 PMCID: PMC5847980 DOI: 10.1136/bcr-2017-223246] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2018] [Indexed: 12/17/2022] Open
Abstract
Dieulafoy's lesion is an abnormally large, tortuous, submucosal vessel that erodes the overlying epithelium without primary ulceration or erosion. The lesion predominantly occurs in the proximal stomach but it is also reported in extragastric sites. The pathogenesis and precipitating factors are poorly understood. Patients frequently present with gastrointestinal haemorrhage that can range from being self-limited to massive life threatening. Although there are no standard guidelines, endoscopy has significantly impacted the diagnosis and management. This review outlines our current understanding of the epidemiology of and risk factors for Dieulafoy's lesion of the duodenum, the pathophysiology of this disorder, and currently available approaches to diagnosis and management.
Collapse
Affiliation(s)
| | - Waseem Amjad
- Northwell-Long Island Jewish Forest Hills Hospital, Forest Hills, NY, USA
| | | | - Abu Hurairah
- SUNY Downstate Medical Center, Brooklyn, NY, USA
| |
Collapse
|
17
|
Abstract
Dieulafoy's lesions (DLs) are rare and cause gastrointestinal bleeding resulting from erosion of dilated submucosal vessels. The most common location for DL is the stomach, followed by duodenum. There is little information about duodenal and jejunal DLs. Challenges for diagnosis and treatment of Dieulafoy's lesions include the rare nature of the disease, asymptomatic patients, bleeding symptoms often requiring rapid diagnosis and treatment in symptomatic patients, variability in the diagnosis and treatment methods resulting from different lesion locations, and the risk of re-bleeding. For these reasons, there is no universal consensus about the diagnosis and treatment approach. There are few published case reports and case series recently published. Most duodenal DLs are not evaluated seperately in the studies, which makes it difficult to determine the optimal model. In this study, we summarize the general aspects and recent approaches used to treat duodenal DL.
Collapse
Affiliation(s)
- Tonguç Utku Yılmaz
- Acibadem University Atakent Hospital, Organ Transplantation Unit, Istanbul, Turkey
| | - Ramazan Kozan
- Eren Hospital, General Surgery Unit, Istanbul, Turkey
| |
Collapse
|
18
|
Chen X, Cao H, Wang S, Wang D, Xu M, Piao M, Wang B. Endoscopic submucosal dissection for silent gastric Dieulafoy lesions mimicking gastrointestinal stromal tumors: Report of 7 cases-a case report series. Medicine (Baltimore) 2016; 95:e4829. [PMID: 27603399 PMCID: PMC5023922 DOI: 10.1097/md.0000000000004829] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Dieulafoy lesion is a rare but serious cause of gastrointestinal hemorrhage. However, some cases can be occasionally found without bleeding during the endoscopic screening, and the management remains unclear. The aim of this article was to report the efficacy and safety of endoscopic submucosal dissection (ESD) for silent gastric Dieulafoy lesions, which presented as protrusion lesions mimicking gastrointestinal stromal tumors (GISTs). METHODS Data from the patients with gastric protrusion lesions who underwent ESD from September 2008 to April 2016 in General Hospital, Tianjin Medical University, China were recorded. Seven cases with pathological diagnosis of Dieulafoy lesion without bleeding were enrolled for further analysis. RESULTS A total of 7 patients (2 males and 5 females) with mean age of 57.7 ± 4.15 years were pathologically diagnosed as Dieulafoy lesion. Four of the lesions were located in gastric antrum, 2 in the fundus, and 1 in the body of stomach, respectively. The mean sizes of the Dieulafoy lesions under white light endoscopy and endoscopic ultrasonography (EUS) were 1.06 ± 0.28 and 0.84 ± 0.29 cm. The origins of these lesions were submucosa (6/7, 85.7%) and muscularis propria (1/7, 14.3%). Three of them appeared with mixed echo under EUS, 3 with hypoechogenicity, and 1 with hyperechogenicity. En bloc complete resection was achieved in all the lesions by ESD with average time of 76.00 ± 16.86 minutes, and no intraoperative bleeding happened. In addition, all patients were followed up for 1 to 53 months, and no recurrence or long-term complications was observed. CONCLUSION Therefore, ESD can be an effective and safe treatment for silent gastric Dieulafoy lesions with clinical presentations of submucosal protrusion lesions mimicking GISTs.
Collapse
Affiliation(s)
- Xue Chen
- Department of Gastroenterology and Hepatology
| | - Hailong Cao
- Department of Gastroenterology and Hepatology
- Correspondence: Hailong Cao, Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Heping District 154 Anshan Road, Tianjin 300052, China (e-mail: )
| | - Sinan Wang
- Department of Gastroenterology and Hepatology
| | - Dan Wang
- Department of Pathology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Mengque Xu
- Department of Gastroenterology and Hepatology
| | - Meiyu Piao
- Department of Gastroenterology and Hepatology
| | | |
Collapse
|
19
|
Sathyamurthy A, Winn JN, Ibdah JA, Tahan V. Culprit for recurrent acute gastrointestinal massive bleeding: “Small bowel Dieulafoy’s lesions” - a case report and literature review. World J Gastrointest Pathophysiol 2016; 7:296-299. [PMID: 27574568 PMCID: PMC4981770 DOI: 10.4291/wjgp.v7.i3.296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/02/2016] [Accepted: 07/18/2016] [Indexed: 02/07/2023] Open
Abstract
A Dieulafoy's lesion is a dilated, aberrant, submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. It can be located anywhere in the gastrointestinal tract. We describe a case of massive gastrointestinal bleeding from Dieulafoy’s lesions in the duodenum. Etiology and precipitating events of a Dieulafoy’s lesion are not well known. Bleeding can range from being self-limited to massive life- threatening. Endoscopic hemostasis can be achieved with a combination of therapeutic modalities. The endoscopic management includes sclerosant injection, heater probe, laser therapy, electrocautery, cyanoacrylate glue, banding, and clipping. Endoscopic tattooing can be helpful to locate the lesion for further endoscopic re-treatment or intraoperative wedge resection. Therapeutic options for re-bleeding lesions comprise of repeated endoscopic hemostasis, angiographic embolization or surgical wedge resection of the lesions. We present a 63-year-old Caucasian male with active bleeding from the two small bowel Dieulafoy’s lesions, which was successfully controlled with epinephrine injection and clip applications.
Collapse
|
20
|
Nojkov B, Cappell MS. Distinctive aspects of peptic ulcer disease, Dieulafoy's lesion, and Mallory-Weiss syndrome in patients with advanced alcoholic liver disease or cirrhosis. World J Gastroenterol 2016; 22:446-466. [PMID: 26755890 PMCID: PMC4698507 DOI: 10.3748/wjg.v22.i1.446] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/11/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy’s lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis.
METHODS: Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: “alcoholic liver disease”, “alcoholic hepatitis”,“ alcoholic cirrhosis”, “cirrhosis”, “liver disease”, “upper gastrointestinal bleeding”, “non-variceal upper gastrointestinal bleeding”, “PUD”, ‘‘DL’’, ‘‘Mallory-Weiss tear”, and “MWS’’.
RESULTS: While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population.
CONCLUSION: Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.
Collapse
|
21
|
Lipka S, Rabbanifard R, Kumar A, Brady P. A single-center United States experience with bleeding Dieulafoy lesions of the small bowel: diagnosis and treatment with single-balloon enteroscopy. Endosc Int Open 2015; 3:E339-45. [PMID: 26356602 PMCID: PMC4554498 DOI: 10.1055/s-0034-1391901] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 02/23/2015] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION A Dieulafoy lesion (DL) of the small bowel can cause severe gastrointestinal bleeding, and presents a difficult clinical setting for endoscopists. Limited data exists on the therapeutic yield of treating DLs of the small bowel using single-balloon enteroscopy (SBE). METHODS Data were collected from Tampa General Hospital a 1 018-bed teaching hospital affiliated with University of South Florida in Tampa, Florida. Patients were selected from a database of patients that underwent SBE from January 2010 - August 2013. RESULTS Eight patients were found to have DL an incidence of 2.6 % of 309 SBE performed for obscure gastrointestinal bleeding. 7/8 were identified in the jejunum, with one found in the duodenum. The mean age of patients with DL was 71.5 years old. 6/8 patients were on some form of anticoagulant/antiplatelet agent. The primary modality of therapy employed was electrocautery, multipolar electrocoagulation in seven patients and APC (argon plasma coagulation) in one patient. In three patients, electrocoagulation was unsuccessful and hemostasis was achieved with clip placement. Three patients required repeat SBE with one found to have rebleeding from a failed clip with hemostasis achieved upon reapplication of one clip. CONCLUSION In our United States' experience, SBE offers a reasonable therapeutic approach to treat DL of the small bowel with low rates of rebleeding, no adverse events, and no patient requiring surgery.
Collapse
Affiliation(s)
- Seth Lipka
- University of South Florida Morsani College of Medicine, Department of Medicine, Tampa, Florida, United States,Corresponding author Seth Lipka, M.D. 12901 Bruce B. Downs Blvd. MDC 72Tampa, Florida 33612United States(813) 805–9863
| | - Roshanak Rabbanifard
- University of South Florida Morsani College of Medicine, Division of Digestive Diseases and Nutrition, Tampa, Florida, United States
| | - Ambuj Kumar
- University of South Florida Morsani College of Medicine, Department of Medicine, Division of Evidence Based Medicine and Outcomes Research, Tampa, Florida, United States
| | - Patrick Brady
- University of South Florida Morsani College of Medicine, Division of Digestive Diseases and Nutrition, Tampa, Florida, United States
| |
Collapse
|
22
|
Abstract
Dieulafoy's lesion (DL) is a persistently wide caliber artery that is observed more frequently at the fifth decade of life in the male population with multiple comorbidities. There are a variety of endoscopic therapies that have been used to treat DL; however, there are no clear guidelines on the best treatment modality. This article systematically reviews the diagnosis, the most commonly reported therapies of DL, and offers a suggested algorithm based upon efficacy of treatment such as initial hemostasis, rebleeding rates, and mortality.
Collapse
|
23
|
Khan R, Mahmad A, Gobrial M, Onwochei F, Shah K. The Diagnostic Dilemma of Dieulafoy's Lesion. Gastroenterology Res 2015; 8:201-206. [PMID: 27785297 PMCID: PMC5040527 DOI: 10.14740/gr671w] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 12/17/2022] Open
Abstract
Dieulafoy’s lesion (DL) is a relatively rare condition which carries a significantly high risk for mortality. A tortuous large arteriole in the wall of the stomach can result in significant gastrointestinal (GI) hemorrhage which can result in detrimental complications. Although it only accounts for about 1% of all GI bleeding, it has been considered to be one of the most underrecognized conditions. This train of thought may unfortunately be related to the difficulty in its diagnosis. After conducting a Medline search of the medical literature, with a focus on current PubMed articles, a thorough examination of updated diagnostic and treatment approaches was compared. Diagnostic techniques in the analysis and treatment of DLs continue to be limited to this day. Endoscopy remains as the main diagnostic and therapeutic tool; however, it continues to have its limitations. Other alternatives include but are not limited to angiography and surgical interventions which at times can be more successful. Diagnostic improvements and research for the detection of DL continue to advance; however, they remain limited in their capabilities. Further analysis and workup needs to be conducted in order to reduce hospital stay and improve survival.
Collapse
Affiliation(s)
- Rafay Khan
- Internal Medicine Department, Raritan Bay Medical Center, 530 New Brunswick Avenue, Perth Amboy, NJ 08861, USA
| | - Abdul Mahmad
- Internal Medicine Department, Raritan Bay Medical Center, 530 New Brunswick Avenue, Perth Amboy, NJ 08861, USA
| | - Mark Gobrial
- Internal Medicine Department, Maimonides Medical Center, 4802 10th Ave, Brooklyn, NY 11219, USA
| | - Francis Onwochei
- Internal Medicine Department, Jersey City Medical Center, 355 Grand St, Jersey City, NJ 07302, USA
| | - Kunal Shah
- St. George's University School of Medicine, University Centre, Grenada, West Indies
| |
Collapse
|
24
|
Outcomes in Dieulafoy's Lesion: A 10-Year Clinical Review. Dig Dis Sci 2015; 60:2097-103. [PMID: 25663242 DOI: 10.1007/s10620-015-3568-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 01/28/2015] [Indexed: 01/30/2023]
Abstract
BACKGROUND Dieulafoy's lesion (DL) is a rare, but serious cause of gastrointestinal bleeding, most frequently treated with endoscopic therapy. We examined 10 years of data to assess clinical outcomes in DL. METHODS Data were captured by retrospective chart review to assess 109 patients treated endoscopically for bleeding DL from 2003 to 2013. Data collected included demographics, comorbidities, presenting symptoms, risk factors, laboratory values, treatment, rebleeding, surgical intervention, and mortality. Treatment success, rebleeding rates, and mortality were the main outcomes measured. RESULTS Of 109 patients with bleeding DL, 54 % were male and 46 % were female. Mean age was 79.4 years; mean follow-up duration was 40.4 ± 35.8 months. Clinical presentation for most patients included melena, hematemesis, hematochezia, and/or anemia with approximately one-third of patients also experiencing anemia-related symptoms. Most lesions were located in stomach (53 %) followed by duodenum/jejunum (33 %) and large intestine (13 %). Thermal endoscopic therapy (70 %) was the most frequently performed procedure followed by injection (46 %) and mechanical (46 %) endoscopy therapy at equal frequency. Combined therapy (51 %) was common, with over half of patients undergoing two or more endoscopic modalities simultaneously. The finding that only 11 (10 %) patients had rebleeding from DL suggests that endoscopic therapy resulted in successful hemostasis in the remaining 98 patients (90 %) during follow-up. Mortality related to DL was low. CONCLUSIONS Most patients with bleeding DL presented with symptoms of acute bleeding, but many had symptoms suggesting subacute or chronic bleeding. Endoscopic therapy resulted in successful hemostasis in approximately 90 % of patients during follow-up. Rebleeding was rare and particularly uncommon in those treated with combined endoscopic therapy.
Collapse
|
25
|
Shin HJ, Ju JS, Kim KD, Kim SW, Kang SH, Kang SH, Moon HS, Sung JK, Jeong HY. Risk Factors for Dieulafoy Lesions in the Upper Gastrointestinal Tract. Clin Endosc 2015; 48:228-33. [PMID: 26064823 PMCID: PMC4461667 DOI: 10.5946/ce.2015.48.3.228] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 10/13/2014] [Accepted: 10/19/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS The purpose of this study is to verify the risk factors associated with Dieulafoy lesion formation in the upper gastrointestinal tract. METHODS A case-control study was performed by reviewing the electronic medical records of 42 patients who were admitted to a tertiary medical center in the Daejeon region for Dieulafoy lesions from September 2008 to October 2013, and the records of 132 patients who were admitted during the same period and who underwent endoscopic examination for reasons other than bleeding. We analyzed clinical and endoscopic findings retrospectively, and searched for risk factors associated with Dieulafoy lesion formation. RESULTS All 42 patients diagnosed with Dieulafoy lesion had accompanying bleeding, and the location of the bleeding was proximal in 25 patients (59.5%), the middle portion in seven patients (16.7%), and distal in 10 patients (23.8%). Antiplatelet agents (p=0.022) and alcohol (p=0.001) use showed statistically significant differences between the two groups. The odds ratios (95% confidence intervals) of the two factors were 2.802 (1.263 to 6.217) and 3.938 (1.629 to 9.521), respectively. CONCLUSIONS This study showed that antiplatelet agents and alcohol consumption were risk factors associated with Dieulafoy lesion formation in the upper gastrointestinal tract.
Collapse
Affiliation(s)
- Hae Jin Shin
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jong Seok Ju
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Ki Dae Kim
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Seok Won Kim
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sung Hoon Kang
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun Hyung Kang
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hee Seok Moon
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Kyu Sung
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyun Yong Jeong
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| |
Collapse
|
26
|
Jeon HK, Kim GH. Endoscopic Management of Dieulafoy's Lesion. Clin Endosc 2015; 48:112-20. [PMID: 25844338 PMCID: PMC4381137 DOI: 10.5946/ce.2015.48.2.112] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 11/02/2014] [Accepted: 11/03/2014] [Indexed: 12/11/2022] Open
Abstract
A Dieulafoy's lesion is a vascular abnormality consisting of a large caliber-persistent tortuous submucosal artery. A small mucosal defect with the eruption of this protruding vessel can cause bleeding. In fact, a Dieulafoy's lesion is a relatively rare but potentially life-threatening condition. It accounts for 1% to 2% of cases of acute gastrointestinal bleeding. Although there is no consensus on the treatment of Dieulafoy's lesions; treatment options depend on the mode of presentation, site of the lesion, and available expertise. Endoscopic therapy is usually successful in achieving primary hemostasis, with hemostasis success rates reaching 75% to 100%. Although various therapeutic endoscopic methods are used to control bleeding in Dieulafoy's lesions, the best method for endoscopic intervention is not clear. Combination endoscopic therapy is known to be superior to monotherapy because of a lower rate of recurrent bleeding. In addition, mechanical therapies including hemostatic clipping and endoscopic band ligation are more effective and successful in controlling bleeding than other endoscopic methods. Advances in endoscopic techniques have reduced mortality in patients with Dieulafoy's lesion-from 80% to 8%-and consequently, the need for surgical intervention has been reduced. Currently, surgical intervention is used for cases that fail therapeutic endoscopic or angiographic interventions.
Collapse
Affiliation(s)
- Hye Kyung Jeon
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| |
Collapse
|
27
|
Dieulafoy lesion in the ascending colon presenting with gastrointestinal bleeding and severe anemia complicated by a coexisting severe resistant chronic idiopathic thrombocytopenic purpura. Case Rep Gastrointest Med 2014; 2014:203678. [PMID: 25405040 PMCID: PMC4227380 DOI: 10.1155/2014/203678] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 10/09/2014] [Indexed: 11/17/2022] Open
Abstract
Background. GI (gastrointestinal) bleeding can be due to a variety of etiologies ranging from being common like bleeding peptic ulcer disease or esophageal varices. One of the rarely documented causes is the Dieulafoy lesion which is known as an abnormally large ectatic artery that penetrates the gut wall, occasionally eroding through the mucosa causing massive bleeding. In addition to that, we refer to the uncommon presentation of Dieulafoy lesion itself as it is well known to be found in the stomach, esophagus, duodenum, and jejunum but not the ascending colon as in our case. The patient had a coexisting ITP (idiopathic thrombocytopenic purpura) that was resistant to different therapies. Case Report. We report a case of a 48-year-old Egyptian female known for chronic ITP resistant to treatment. The patient presented with bright red bleeding per rectum and severe life threatening anemia. Endoscopic study showed a Dieulafoy lesion. Endoscopic clipping was successful in controlling the bleeding. Conclusion. Dieulafoy lesion is a rare reason for GI bleeding and can present in common or unexpected places. Also extreme caution should be used in patients with bleeding tendency due to different reasons, like ITP in our case.
Collapse
|
28
|
Irwin J, Ferguson R, Weilert F, Smith A. Factors at presentation predictive of a requirement for endoscopic therapy in patients presenting with overt upper gastrointestinal haemorrhage: a retrospective observational study. Frontline Gastroenterol 2014; 5:2-9. [PMID: 28839744 PMCID: PMC5369709 DOI: 10.1136/flgastro-2013-100340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/13/2013] [Accepted: 06/15/2013] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION In patients with upper gastrointestinal haemorrhage (UGIH), endoscopic treatment of high-risk lesions reduces mortality. Performing out of office hours endoscopy places a strain on endoscopy services. This analysis aims to identify factors at presentation associated with lesions requiring endoscopic therapy, allowing triage of those likely to receive benefit from acute out of hours endoscopy. METHODS Patients presenting between 17 March 2001 and 12 October 2010 with UGIH had clinical and laboratory features on presentation, endoscopic findings and administered treatment recorded. Patients with known cirrhotic liver disease were excluded. Logistic regression was performed, identifying factors at presentation associated with a requirement of endoscopic therapy (RET), which were then used to create a scoring system predictive of RET. RESULTS In all, 1492 patients were analysed. The presence on presentation of fresh melaena (OR = 3.18, p<0.001), fresh haematemesis (OR=2.13, p<0.001), haemoglobin<130 g/L (OR=2.65, p<0.001), urea >10 mmol/L (OR=2.10, p<0.001), systolic blood pressure <100 mm Hg (OR=1.85, p<0.001), inpatient status (OR=1.43, p=0.04), a history of peptic ulcer disease (OR=1.96, p=0.02), male sex (OR=1.45, p=0.01), presentation within 8 h of symptom onset (OR=1.48, p=0.02), coffee ground vomitus (OR=0.47, p=0.004) and warfarin use (OR=0.57, p=0.005) were associated with RET. Using a simple scoring system (fresh haematemesis=2, fresh melaena=2, haemoglobin <130=2, urea >10=1, BP <100=1, male sex=1, history of peptic ulcer disease=1), a score ≥7 was associated with RET in 45% of cases and a score ≤4 in 7%. CONCLUSIONS Application of this scoring system when assessing patients presenting with UGIH out of office hours may help predict the likelihood of RET, and aid in the triage of endoscopy. Prospective validation of this score in an external cohort is required.
Collapse
Affiliation(s)
- James Irwin
- Department of Gastroenterology, Waikato Hospital, Hamilton, New Zealand
| | - Reid Ferguson
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Frank Weilert
- Department of Gastroenterology, Waikato Hospital, Hamilton, New Zealand
| | - Anthony Smith
- Department of Gastroenterology, Waikato Hospital, Hamilton, New Zealand
| |
Collapse
|
29
|
Choi YC, Park SH, Bang BW, Kwon KS, Kim HG, Shin YW. Two cases of ileal dieulafoy lesion with massive hematochezia treated by single balloon enteroscopy. Clin Endosc 2012; 45:440-3. [PMID: 23251897 PMCID: PMC3521951 DOI: 10.5946/ce.2012.45.4.440] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 01/13/2012] [Accepted: 01/25/2012] [Indexed: 12/12/2022] Open
Abstract
Ileal Dieulafoy lesion is an unusual vascular abnormality that can cause gastrointestinal bleeding. It can be associated with massive, life-threatening hemorrhage and requires urgent angiographic intervention or surgery. Ileal Dieulafoy lesion is hard to recognize due to inaccessibility and normal-appearing mucosa. With advances in endoscopy, aggressive diagnostic and therapeutic approaches including enteroscopy have recently been performed for small bowel bleeding. We report two cases of massive ileal Dieulafoy lesion bleeding diagnosed and treated successfully by single balloon enteroscopy with a review of the literature.
Collapse
Affiliation(s)
- Young Chul Choi
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | | | | | | | | | | |
Collapse
|
30
|
Non-variceal gastrointestinal bleeding in patients with liver cirrhosis: a review. Dig Dis Sci 2012; 57:2743-54. [PMID: 22661272 DOI: 10.1007/s10620-012-2229-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 05/01/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Non-variceal gastrointestinal (NVGI) bleeding in cirrhosis may be associated with life-threatening complications similar to variceal bleeding. AIM To review NVGI bleeding in cirrhosis. METHODS MEDLINE, Scopus, and ISI Web of Knowledge were searched, using the textwords "portal hypertensive gastropathy," "gastric vascular ectasia," "peptic ulcer," "Dieulafoy's," "Mallory-Weiss syndrome," "portal hypertensive enteropathy," "portal hypertensive colopathy," "hemorrhoids," and "cirrhosis." RESULTS Portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE) are gastric lesions that most commonly present as chronic anemia; acute upper GI (UGI) bleeding is a rare manifestation. Management of PHG-related bleeding is mainly pharmacological, whereas endoscopic intervention is favored in GVE-related bleeding. Shunt therapies or more invasive techniques are restricted in refractory cases. Despite its high incidence in cirrhotic patients, peptic ulcer accounts for a relatively small proportion of UGI bleeding in this patient population. However, in contrary to general population, the pathogenetic role of Helicobacter pylori infection remains questionable. Finally, other causes of UGI bleeding include Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids. However, the vast majority of studies are case reports and, therefore, the incidence, diagnosis, and risk of bleeding remain undefined. Endoscopic interventions, shunting procedures, and surgical techniques have been described in this setting. CONCLUSIONS The data on NVGI bleeding in liver cirrhosis are surprisingly scanty. Large, multicenter epidemiological studies are needed to better assess prevalence and incidence and, most importantly, randomized studies should be performed to evaluate the success rates of therapeutic algorithms.
Collapse
|
31
|
Jamanca-Poma Y, Velasco-Guardado A, Piñero-Pérez C, Calderón-Begazo R, Umaña-Mejía J, Geijo-Martínez F, Rodríguez-Pérez A. Prognostic factors for recurrence of gastrointestinal bleeding due to Dieulafoy's lesion. World J Gastroenterol 2012; 18:5734-8. [PMID: 23155314 PMCID: PMC3484342 DOI: 10.3748/wjg.v18.i40.5734] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 07/26/2012] [Accepted: 07/28/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the effectiveness of the endoscopic therapy and to identify prognostic factors for recurrent bleeding.
METHODS: Retrospective study of patients with gastrointestinal bleeding secondary to Dieulafoy’s lesion (DL) from 2005 to 2011. We analyzed the demographic characteristics of the patients, risk factors for gastrointestinal bleeding, endoscopic findings, characteristics of the endoscopic treatment, and the recurrence of bleeding. We included cases in which endoscopy described a lesion compatible with Dieulafoy. We excluded patients who had potentially bleeding lesions such as angiodysplasia in other areas or had undergone other gastrointestinal endoscopic procedures.
RESULTS: Twenty-nine patients with DL were identified. Most of them were men with an average age of 71.5 years. Fifty-five percent of the patients received antiaggregatory or anticoagulant therapy. The most common location for DL was the stomach (51.7%). The main type of bleeding was oozing in 65.5% of cases. In 27.6% of cases, there was arterial (spurting) bleeding, and 6.9% of the patients presented with an adherent clot. A single endoscopic treatment was applied to nine patients (31%); eight of them with adrenaline and one with argon, while 69% of the patients received combined treatment. Six patients (20.7%) presented with recurrent bleeding at a median of 4 d after endoscopy (interquartile range = 97.75). Within these six patients, the new endoscopic treatment obtained a therapeutic success of 100%. The presence of arterial bleeding at endoscopy was associated with a higher recurrence rate for bleeding (50% vs 33.3% for other type of bleeding) [P = 0.024, odds ratio (OR) = 8.5, 95% CI = 1.13-63.87]. The use of combined endoscopic treatment prevented the recurrence of bleeding (10% vs 44.4% of single treatment) (P = 0.034, OR = 0.14, 95% CI = 0.19-0.99).
CONCLUSION: Endoscopic treatment of DL is safe and effective. Adrenaline monotherapy and arterial (spurting) bleeding are associated with a high rate of bleeding recurrence.
Collapse
|
32
|
Beyazit Y, Kekilli M, Haznedaroglu IC, Kayacetin E, Basaranoglu M. Ankaferd hemostat in the management of gastrointestinal hemorrhages. World J Gastroenterol 2011; 17:3962-70. [PMID: 22046083 PMCID: PMC3199553 DOI: 10.3748/wjg.v17.i35.3962] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 03/01/2011] [Accepted: 03/08/2011] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal (GI) bleeding refers to any hemorrhage ascribed to the pathologies of the gastrointestinal tract, extending from the mouth to the anal canal. Despite the recent improvements in the endoscopic, hemostatic and adjuvant pharmacologic techniques, the reported mortality is still around 5%-10% for peptic ulcer bleeding and about 15%-20% for variceal hemorrhages. Although endoscopic management reduces the rates of re-bleeding, surgery, and mortality in active bleeding; early recurrence ratios still occur in around 20% of the cases even with effective initial hemostatic measures. In this quest for an alternative pro-hemostatic agent for the management of GI bleedings, Ankaferd blood stopper (ABS) offers a successful candidate, specifically for “difficult-to-manage” situations as evidenced by data presented in several studies. ABS is a standardized mixture of the plants Thymus vulgaris, Glycyrrhiza glabra, Vitis vinifera, Alpinia officinarum, and Urtica dioica. It is effective in both bleeding individuals with normal hemostatic parameters and in patients with deficient primary and/or secondary hemostasis. ABS also modulates the cellular apoptotic responses to hemorrhagic stress, as well as hemostatic hemodynamic activity. Through its effects on the endothelium, blood cells, angiogenesis, cellular proliferation, vascular dynamics, and wound healing, ABS is now becoming an effective alternative hemostatic medicine for gastrointestinal bleedings that are resistant to conventional anti-hemorrhagic measurements. The aim of this review is to outline current literature experience suggesting the place of ABS in the management of GI bleeding, and potential future controlled trials in this complicated field.
Collapse
|
33
|
Dulic-Lakovic E, Dulic M, Hubner D, Fuchssteiner H, Pachofszky T, Stadler B, Maieron A, Schwaighofer H, Püspök A, Haas T, Gahbauer G, Datz C, Ordubadi P, Holzäpfel A, Gschwantler M. Bleeding Dieulafoy lesions of the small bowel: a systematic study on the epidemiology and efficacy of enteroscopic treatment. Gastrointest Endosc 2011; 74:573-80. [PMID: 21802676 DOI: 10.1016/j.gie.2011.05.027] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 05/05/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Dieulafoy lesions consist of aberrant submucosal arteries, which can cause severe GI bleeding. The predominant location of Dieulafoy lesions is the upper GI tract. OBJECTIVE 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. DESIGN Multicenter, retrospective, observational study. SETTING Nine Austrian centers doing double-balloon enteroscopy or single-balloon enteroscopy. PATIENTS This study involved 284 consecutive patients who were referred for double-balloon enteroscopy or single-balloon enteroscopy because of suspicion of mid-GI bleeding. INTERVENTION A total of 317 double-balloon enteroscopy and 78 single-balloon enteroscopy procedures were performed in 284 patients with suspected mid-GI bleeding. MAIN OUTCOME MEASUREMENTS Demographic, clinical, procedural, and outcome data were collected. RESULTS 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. LIMITATIONS Retrospective study. CONCLUSION 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.
Collapse
|
34
|
Patel P, Tobi M. Dieulafoy-like lesion bleeding: in the loop. Gastroenterol Hepatol (N Y) 2011; 7:271-274. [PMID: 21857828 PMCID: PMC3127032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Pragnesh Patel
- Geriatrics Division, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan
| | - Martin Tobi
- Section of Gastroenterology, Philadelphia VA Medical Center and Division of Gastroenterology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
35
|
Eddi R, Shah N, Depasquale JR. Gastrointestinal Bleeding Due to a Dieulafoy Lesion in the Afferent Limb of a Billroth II Reconstruction. Gastroenterol Hepatol (N Y) 2011; 7:268-271. [PMID: 21857827 PMCID: PMC3127031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
|
36
|
Turner JD, Bavakunji RV, Selby NM. A rare cause of massive upper gastrointestinal bleeding in a dialysis patient: synchronous Dieulafoy lesions. Clin Kidney J 2010; 3:594-5. [PMID: 25949479 PMCID: PMC4421416 DOI: 10.1093/ndtplus/sfq151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 07/27/2010] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jake D Turner
- Department of Renal Medicine , Royal Derby Hospital , Uttoxeter Road, Derby, DE22 3NE , UK
| | - Riaz V Bavakunji
- Department of Renal Medicine , Royal Derby Hospital , Uttoxeter Road, Derby, DE22 3NE , UK
| | - Nick M Selby
- Department of Renal Medicine , Royal Derby Hospital , Uttoxeter Road, Derby, DE22 3NE , UK
| |
Collapse
|
37
|
Dieulafoy lesions of the GI tract: localization and therapeutic outcomes. Dig Dis Sci 2010; 55:3436-41. [PMID: 20848205 DOI: 10.1007/s10620-010-1385-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 08/02/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Dieulafoy lesions are a rare cause of gastrointestinal hemorrhage with a striking presentation because of rapid blood loss. Endoscopic therapy is usually successful at achieving primary hemostasis, but the best mode of endoscopic intervention is not clear, and outcomes relating to variables such as gender, medication, alcohol, and smoking are not known. We reviewed the clinical experience with Dieulafoy lesions at our institution, focusing on clinico-epidemiological features, management practices, and also survival. METHODS A retrospective and prospective cohort of patients with Dieulafoy lesions who underwent endoscopy from January 2004 through April 2009 were studied and detailed clinical data were abstracted and collected. RESULTS We identified 63 patients with a Dieulafoy lesion. The majority were male with an average age 58 years. Hematemesis and melena were the most common presenting symptoms. Almost half the patients were on anticoagulation medication. Most of the Dieulafoy lesions occurred in the upper GI tract, and mostly in the stomach. Single-modality endoscopic therapy was used as frequently as combination therapy, and both were effective, as primary hemostasis was achieved in 92% of cases. There were 11 deaths overall; death due to Dieulafoy lesion exsanguination was attributed to three patients. CONCLUSIONS Dieulafoy lesions occurred in younger patients than previously reported, and were more frequently diagnosed in males. Most DL lesions occurred in the upper GI tract. Primary hemostasis with endoscopic therapy was highly successful. Overall mortality was 17%, and associated with co-morbidities, and not with medical history, gender, age, or medication.
Collapse
|
38
|
Abstract
AIM: To investigate the incidence, location, clinical presentation, diagnosis and effectiveness of endoscopic treatment of gastric Dieulafoy’s lesion (DL) in China.
METHODS: All patients who received emergency upper gastrointestinal (GI) endoscopy due to gastric DL from February 2000 to August 2008 at GI endoscopy center of Renmin Hospital of Wuhan University were included in this study. The clinical presentation, medical history, location and characteristics of DL methods and effectiveness of therapy of patients with DL were retrospectively analysed by chart reviews. Long-term follow-up data were collected at outpatient clinics or telephone interviews.
RESULTS: Fifteen patients were diagnosized with DL, which account for 1.04% of the source of bleeding in acute non-variceal upper GI bleeding. Common comorbidities were found in one patient with hypertension and diabetic mellitus. Hemoclip or combined therapy with hemoclip produced primary hemostasis in 92.8% (13/14) of patients.
CONCLUSION: DL is uncommon but life-threatening in China. Hemoclip proved to be safe and effective in controlling bleeding from DL.
Collapse
|
39
|
Lim W, Kim TO, Park SB, Rhee HR, Park JH, Bae JH, Jung HR, Kim MR, Lee N, Lee SM, Kim GH, Heo J, Song GA. Endoscopic treatment of dieulafoy lesions and risk factors for rebleeding. Korean J Intern Med 2009; 24:318-22. [PMID: 19949729 PMCID: PMC2784974 DOI: 10.3904/kjim.2009.24.4.318] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Accepted: 04/18/2009] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Dieulafoy lesions are an important cause of upper gastrointestinal bleeding. The purpose of this study was to assess the efficacy of endoscopic treatment for these lesions and to identify the possible predictive factors for rebleeding associated with clinical and endoscopic characteristics. METHODS Records from 44 patients admitted with Dieulafoy bleeding between January 2006 and December 2007 were reviewed. We retrospectively analyzed the clinical and endoscopic findings and then correlated the rebleeding risk factors with Dieulafoy lesions. RESULTS Primary hemostasis was achieved by endoscopic treatment in 39 patients (88.6%). There were no significant differences between the rebleeding and non-rebleeding groups with respect to age, gender, initial hemoglobin levels, presence of shock, concurrent disease, location of bleeding, or initial hemostatic treatment methods. However, the use of non-steroidal anti-inflammatory drugs or anticoagulants (p=0.02) and active stages in the Forrest classification (p<0.01) were risk factors for rebleeding after endoscopic therapy. CONCLUSIONS Endoscopic therapy is effective and safe for treating Dieulafoy lesions, and it has both short- and long-term benefits. Early identification of risk factors such as the use of non-steroidal anti-inflammatory drugs or anticoagulants and the Forrest classification of bleeding predict the outcome of Dieulafoy lesions.
Collapse
Affiliation(s)
- Won Lim
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Tae Oh Kim
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Su Bum Park
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Ha Rin Rhee
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Jin Hyun Park
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Jung Ho Bae
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Hong Ryeul Jung
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Mi Ra Kim
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - NaRiA Lee
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Sun Mi Lee
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Jeong Heo
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| |
Collapse
|
40
|
Lim W, Kim TO, Park SB, Rhee HR, Park JH, Bae JH, Jung HR, Kim MR, Lee N, Lee SM, Kim GH, Heo J, Song GA. Endoscopic treatment of dieulafoy lesions and risk factors for rebleeding. Korean J Intern Med 2009. [PMID: 19949729 DOI: 10.3904/kjim.2009.24.4318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Dieulafoy lesions are an important cause of upper gastrointestinal bleeding. The purpose of this study was to assess the efficacy of endoscopic treatment for these lesions and to identify the possible predictive factors for rebleeding associated with clinical and endoscopic characteristics. METHODS Records from 44 patients admitted with Dieulafoy bleeding between January 2006 and December 2007 were reviewed. We retrospectively analyzed the clinical and endoscopic findings and then correlated the rebleeding risk factors with Dieulafoy lesions. RESULTS Primary hemostasis was achieved by endoscopic treatment in 39 patients (88.6%). There were no significant differences between the rebleeding and non-rebleeding groups with respect to age, gender, initial hemoglobin levels, presence of shock, concurrent disease, location of bleeding, or initial hemostatic treatment methods. However, the use of non-steroidal anti-inflammatory drugs or anticoagulants (p=0.02) and active stages in the Forrest classification (p<0.01) were risk factors for rebleeding after endoscopic therapy. CONCLUSIONS Endoscopic therapy is effective and safe for treating Dieulafoy lesions, and it has both short- and long-term benefits. Early identification of risk factors such as the use of non-steroidal anti-inflammatory drugs or anticoagulants and the Forrest classification of bleeding predict the outcome of Dieulafoy lesions.
Collapse
Affiliation(s)
- Won Lim
- Department of Internal Medicine, Pusan National University College of Medicine, Seo-gu, Busan, Korea
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Khan MI, Baqai MT, Baqai MF, Mufti N. Exsanguinating upper GI bleeds due to Unusual Arteriovenous Malformation (AVM) of stomach and spleen: a case report. World J Emerg Surg 2009; 4:15. [PMID: 19409093 PMCID: PMC2687422 DOI: 10.1186/1749-7922-4-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 05/01/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In this paper we are reporting one case of exsanguinating upper gastrointestinal tract (GIT) bleed requiring massive blood transfusion and immediate life saving surgery. CASE PRESENTATION A 30 years old female, 12 weeks pregnant was referred to our hospital from the earth-quake affected area of Kashmir with history of upper abdominal pain, haematemesis and melaena for one week. After stabilizing the patient, upper gastro-intestinal endoscopy was performed. It revealed gastric ulcer just distal to the gastro-esophageal junction on the lesser curvature. Biopsy from the ulcer edge led to profuse spurting of the blood and patient went into state of shock. Immediate resuscitation led to rebleeding and recurrence of post haemorrahagic shock. CONCLUSION The patient was immediately explored and total gastrectectomy with splenectomy concluded as life saving procedure. A review of literature was conducted to make this report possible.
Collapse
Affiliation(s)
- Mohammad Iqbal Khan
- Department of surgery, Islamic International Medical College, Rawalpindi, Pakistan.
| | | | | | | |
Collapse
|
42
|
|
43
|
Abstract
Dieulafoy disease is an uncommon cause of gastrointestinal system bleeding. Although the exact cause is not known, it is characterized by bleeding from abnormal submucosal vessels. There are many methods for diagnosis and treatment. In this case, a patient with a long-time undiagnosed stomach Dieulafoy lesion had a surgical resection. During the postoperative period the patient was discharged without any complication.
Collapse
Affiliation(s)
- A Isik
- Vakif Gureba Training and Research Hospital, Fatih, Istanbul, Turkey
| | | | | | | | | | | |
Collapse
|
44
|
Wade AD, Kothari SN. Dieulafoy lesion after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2008; 5:135-6. [PMID: 18708304 DOI: 10.1016/j.soard.2008.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 05/05/2008] [Accepted: 05/20/2008] [Indexed: 11/16/2022]
Affiliation(s)
- Alexander D Wade
- Surgery Residency, Gundersen Lutheran Medical Foundation, La Crosse, Wisconsin, USA
| | | |
Collapse
|
45
|
Siddiqui T, Parnaby C, Mackay C. Duodenal Dieulafoy's Lesion: A Case Report. Scott Med J 2008. [DOI: 10.1258/rsmsmj.53.3.57e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Dieulafoy's lesion is an uncommon but important cause of recurrent upper gastrointestinal bleeding. Extragastric location of Dieulafoy's lesion is extremely rare. We report a case of upper gastrointestinal haemorrhage due to Dieulafoy's lesion of the duodenum and discuss the management of this extremely uncommon entity.
Collapse
Affiliation(s)
- T Siddiqui
- Department of General Surgery, The Southern General Hospital, Glasgow, Scotland, UK
| | - C Parnaby
- Department of General Surgery, The Southern General Hospital, Glasgow, Scotland, UK
| | - C Mackay
- Department of General Surgery, The Southern General Hospital, Glasgow, Scotland, UK
| |
Collapse
|
46
|
Borda Celaya F, Amorena Muro E, Juanmartiñena Fernández F, Javier Jiménez Pérez F, José Vila Costas J, Arin Letamendia A. ¿Presenta características diferenciales la hemorragia digestiva alta por lesión de Dieulafoy? GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:335-40. [DOI: 10.1157/13123600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
47
|
Cost-effectiveness of proton-pump inhibition before endoscopy in upper gastrointestinal bleeding. Clin Gastroenterol Hepatol 2008; 6:418-25. [PMID: 18304891 DOI: 10.1016/j.cgh.2007.12.037] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Randomized trials suggest high-dose proton-pump inhibitors (PPIs) administered before gastroscopy in suspected upper gastrointestinal bleeding downstage bleeding ulcer stigmata. We assessed the cost-effectiveness of this approach. METHODS A decision model compared high-dose IVPPI initiated while awaiting endoscopy with IVPPI administration on the basis of endoscopic findings. IVPPIs were given to all patients undergoing endoscopic hemostasis for 72 hours thereafter. Once the IV regimen was completed or for patients with low-risk endoscopic lesions, an oral daily PPI was given for the remainder of the time horizon (30 days after endoscopy). The unit of effectiveness was the proportion of patients without rebleeding, representing the denominator of the cost-effectiveness ratio (cost per no rebleeding). Probabilities and costs were derived from the literature and national databases. RESULTS IVPPIs before endoscopy were both slightly more costly and effective than after gastroscopy in the U.S. and Canadian settings, with cost-effectiveness ratios of US$5048 versus $4933 and CAN$6064 versus $6025 and incremental costs of US$45,673 and CAN$19,832 to prevent one additional rebleeding episode, respectively. Sensitivity analyses showed robust results in the US In Canada, intravenous proton-pump inhibitors (IVPPIs) before endoscopy became more effective and less costly (dominant strategy) when the uncomplicated stay for high-risk patients increased above 6 days or that of low-risk patients decreased below 3 days. CONCLUSIONS With conservative estimates and high-quality data, IVPPIs given before endoscopy are slightly more effective and costly than no administration. In Canada, this approach becomes dominant as the duration of hospitalization for high-risk ulcer patients increases or that of low-risk ulcer patients decreases.
Collapse
|
48
|
Iacopini F, Petruzziello L, Marchese M, Larghi A, Spada C, Familiari P, Tringali A, Riccioni ME, Gabbrielli A, Costamagna G. Hemostasis of Dieulafoy's lesions by argon plasma coagulation (with video). Gastrointest Endosc 2007; 66:20-6. [PMID: 17591469 DOI: 10.1016/j.gie.2006.11.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Accepted: 11/10/2006] [Indexed: 02/06/2023]
Abstract
BACKGROUND A Dieulafoy's lesion is a submucosal artery that may erode the epithelium and lead to severe hemorrhages. The safety and efficacy of argon plasma coagulation (APC) for the hemostasis of these lesions has not been studied. OBJECTIVE To evaluate efficacy of APC alone in the hemostasis of Dieulafoy's lesions. DESIGN A retrospective analysis of hemostasis by chart review, with long-term follow-up by outpatient visit or phone interview. SETTING An academic hospital with 24-hour endoscopic service availability. PATIENTS All patients with acute bleeding from a Dieulafoy's lesion treated with APC. INTERVENTIONS Hemostasis was attempted with 2.3-mm APC probes, with settings varying from 40 W to 60 W, according to lesion location. MAIN OUTCOME MEASUREMENTS Initial hemostasis, recurrent bleeding, and 30-day mortality rates. RESULTS Twenty-three Dieulafoy's lesions were treated with APC, which represented 85% of all such lesions observed. Severe comorbidities and abnormal coagulation were present in 39% and 22%, respectively. Dieulafoy's lesions were located in the upper-GI tract in 20 patients (87%). Active bleeding was found in 20 patients (87%), a nonbleeding visible vessel was found in 2 patients (9%), and a minute mucosal defect below an adherent clot was found in 1 (4%). Initial hemostasis was achieved in all patients, without complications. An injection of an average volume of 3 mL of 1:10,000 epinephrine solution preceded APC in 3 cases for the identification of the bleeding lesion. Recurrent bleeding occurred in a patient after 48 hours; no bleeding-related deaths were observed during a median follow-up of 29 months. LIMITATIONS Retrospective study. CONCLUSIONS Dieulafoy's lesions can be successfully managed by APC alone.
Collapse
Affiliation(s)
- Federico Iacopini
- Digestive Endoscopy Unit, Department of Surgery, Catholic University, Rome, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Nandi B, Hota PK, Ganjoo RK. Dieulafoy's Lesion: An uncommon cause of Upper Gastrointestinal Bleeding. Med J Armed Forces India 2006; 62:284-5. [PMID: 27407912 DOI: 10.1016/s0377-1237(06)80024-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2004] [Accepted: 09/20/2005] [Indexed: 01/04/2023] Open
Affiliation(s)
- B Nandi
- Classified Specialist (Medicine and Gastroenterology), CH (AF) Bangalore
| | - P K Hota
- Classified Specialist (Surgery) MH Jabalpur
| | | |
Collapse
|
50
|
De Palma GD, Patrone F, Rega M, Simeoli I, Masone S, Persico G. Actively bleeding Dieulafoy’s lesion of the small bowel identified by capsule endoscopy and treated by push enteroscopy. World J Gastroenterol 2006; 12:3936-7. [PMID: 16804987 PMCID: PMC4087950 DOI: 10.3748/wjg.v12.i24.3936] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Dieulafoy’s lesion is an unusual cause of recurrent GI bleeding. This report describes a case of actively bleeding Dieulafoy’s lesion of the small bowel in which the diagnosis was made by capsule endoscopy, followed by treatment with the use of push enteroscopy. The case illustrates that capsule endoscopy and enteroscopy are highly complementary in patients with small bowel diseases.
Collapse
Affiliation(s)
- Giovanni D De Palma
- Centro per l'Innovazione Tecnologica in Chirurgia, Dipartimento di Chirurgia Generale, Oncologica e Tecnologie Avanzate, Universita degli Studi di Napoli Federico II-Facolta di Medicina e Chirurgia, Italy.
| | | | | | | | | | | |
Collapse
|