1
|
Huynh TM, Le QD, Luu MN, Nguyen TTH, Bui QN, Mai APT, Tran THD, Tran HM, Vo CHM, Quach DT. A Multidisciplinary approach to treat massive recurrent hematochezia from a jejunal Dieulafoy lesion: A case report. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022; 11:135-138. [DOI: 10.18528/ijgii220007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 09/25/2023] Open
Affiliation(s)
- Tien Manh Huynh
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, Vietnam
| | - Quang Dinh Le
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, Vietnam
| | - Mai Ngoc Luu
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, Vietnam
| | | | | | | | | | | | | | - Duc Trong Quach
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, Vietnam
- Nhan Dan Gia Dinh Hospital, Ho Chi Minh, Vietnam
| |
Collapse
|
2
|
Kalantari ME, Sardarzadeh N, Mirsadeghi A, Bagherzadeh AA, Zandbaf T. Jejunal Dieulafoy's Lesion as a Rare Cause of Massive Gastrointestinal Bleeding; a Case Report and Literature Review. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e61. [PMID: 36033991 PMCID: PMC9397588 DOI: 10.22037/aaem.v10i1.1623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Jejunal Dieulafoy's lesion is difficult to diagnose due to its rarity, intermittent hemorrhage, and lesion site, which is largely inaccessible to conventional endoscopes. A 39-year-old man, who had no underlying disease, presented to the emergency department (ED) with weakness, dizziness, and dry cough with a history of several rectal bleeding episodes in the last few years. Endoscopy was normal, and the colon was full of clots on colonoscopy, and no gross pathology was found. On computed tomography (CT) angiography, a hyperdensity was seen in the middle of the jejunum, possibly suggesting contrast extravasation. Due to decreased hemoglobin of the patient, and hemodynamic instability, the patient became a candidate for surgery. A palpable lesion in the Jejunum was touched that opened longitudinally, which revealed active arterial bleeding from the nipple-like lesion. This segment was resected, and an anastomosis was performed. Histopathological examination of the small intestine confirmed a Dieulafoy's lesion. It seems that, when upper endoscopy and colonoscopy fail to identify the cause of gastrointestinal bleeding, a Dieulafoy's lesion should be included in the differential diagnoses.
Collapse
Affiliation(s)
| | - Newsha Sardarzadeh
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Mirsadeghi
- Department of General Surgery, Faculty of Medicine, Mashhad Medical Sciences, Islamic Azad University, Mashhad, Iran
| | - Ali Akbar Bagherzadeh
- Innovative Medical Research Center, Faculty of Medicine, Mashhad Medical Sciences, Islamic Azad University, Mashhad, Iran
| | - Tooraj Zandbaf
- Department of General Surgery, Faculty of Medicine, Mashhad Medical Sciences, Islamic Azad University, Mashhad, Iran,Corresponding author: Tooraj Zandbaf; Faculty of Medicine, Bazarche Sarab, Imam Khomeini 14, Mashhad, Iran. ,https://orcid.org/0000-0002-4882-5058, Tel:+98-9155114523 ; +98-513-2250041 ,Fax Number: +98-513-2250048
| |
Collapse
|
3
|
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
|
4
|
Yehya M, Mayovska O, Flick A, Moszczynski Z. A Jejunal Dieulafoy Lesion: Rare Case Necessitating Surgical Intervention. Int J Surg Case Rep 2020; 72:541-545. [PMID: 32698284 PMCID: PMC7327865 DOI: 10.1016/j.ijscr.2020.06.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 11/25/2022] Open
Abstract
Dieulafoy lesions are aberrant submucosal lesions that, in rare circumstances, can result in massive gastrointestinal bleeding. These lesions are particularly rare in the jejunum, thus usual diagnostic and therapeutic modalities such as endoscopy may prove difficult. Additional imaging such as angiography or radionuclide scanning can be beneficial in identifying the source of bleeding. If advanced endoscopic instruments are unavailable at one’s facility, the surgeon must consider operative intervention for life-saving measures. The operative findings and management discussed can guide clinicians unexposed to this disease process when surgical intervention is imminent. Introduction Dieulafoy lesions are enlarged atypical submucosal vessels that erode the superimposing epithelium in the absence of a primary ulcer. They occur predominantly in the gastric mucosa; however, cases have been seen throughout the gastrointestinal (GI) tract, and rarely, the jejunum. These lesions can cause massive GI hemorrhage leading to shock. Case Presentation We present a healthy 19-year-old male who arrived at our institution’s emergency department with multiple episodes of hematemesis and hematochezia that began earlier that morning. The patient was resuscitated and underwent a computerized tomographic (CT) angiography that did not identify any areas of active extravasation. The patient was then taken for an emergent upper and lower endoscopy that was inconclusive. He was subsequently sent for a tagged red blood cell scan, which demonstrated active bleeding in the proximal jejunum. Shortly thereafter, the patient began to decompensate requiring additional blood products and vasopressors. The decision was made for immediate operative intervention, which identified the bleeding Dieulafoy lesion (confirmed by histopathology) in the jejunum. Discussion Dieulafoy lesions are rare with an initial presentation of upper or lower GI bleeding, generally treated with endoscopic intervention. They are predominately found in the stomach or duodenum. When no clear source is identified by endoscopy, further diagnostic testing may be of value. Various imaging modalities exist; however, CT angiography or radionuclide scanning are particularly sensitive and can be beneficial in localizing the bleed when preparing for operative intervention. Conclusion With advances in endoscopic techniques, surgical intervention is rarely performed for a Dieulafoy lesion. If endoscopy is unsuccessful, additional imaging can be obtained to localize the source of bleeding. However, in emergent cases, when additional imaging cannot be obtained due to lack of time or resources, adequate resection of the lesion should be performed for complete resolution of the disease process. Based on the case presentation and pathologic findings, this case provides further insight into Dieulafoy lesions and the rare need for surgical management.
Collapse
Affiliation(s)
- Misbah Yehya
- Department of Surgery, Carepoint Health Bayonne Medical Center, Bayonne, NJ, USA.
| | - Oksana Mayovska
- Department of Surgery, Carepoint Health Bayonne Medical Center, Bayonne, NJ, USA.
| | - Amanda Flick
- Department of Surgery, Carepoint Health Bayonne Medical Center, Bayonne, NJ, USA.
| | - Zbigniew Moszczynski
- Department of Surgery, Carepoint Health Bayonne Medical Center, Bayonne, NJ, USA.
| |
Collapse
|
5
|
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
|
6
|
Oladunjoye O, Oladunjoye A, Slater L, Jehangir A. Dieulafoy lesion in the jejunum: a rare cause of massive gastrointestinal bleeding. J Community Hosp Intern Med Perspect 2020; 10:138-139. [PMID: 32850049 PMCID: PMC7426710 DOI: 10.1080/20009666.2020.1742521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Dieulafoy lesions are tortuous vascular malformations characterized by thick walled
submucosal arteries/large caliber arterioles protruding through a small mucosal defect
surrounded by normal mucosa. They can occur in the jejunum/ileum and can cause massive,
life-threatening GI bleeding. We present an 80-year-old female with three weeks of black
tarry stools, progressive dyspnea on exertion and generalized body weakness with no
significant findings on Esophagogastroduodenoscopy (EGD). Push enteroscopy revealed
a Dieulafoy lesion in the proximal jejunum and an overlying clot, with oozing of blood
noted after clot removal. The lesion was treated with Argon plasma coagulation (APC) and a
post-APC fleshy protuberance was clipped to secure hemostasis. It is therefore important
to keep a high index of suspicion for jejunal/ileal Dieulafoy lesions in patients with
massive GI bleeding of unclear etiology on EGD/colonoscopy.
Collapse
Affiliation(s)
- Olubunmi Oladunjoye
- Department of Internal Medicine, Reading Hospital - Tower Health, West Reading, PA, USA
| | - Adeolu Oladunjoye
- Department of Medical Critical Care, Boston Children's Hospital, Boston, MA, USA
| | - Lydia Slater
- Department of Internal Medicine, Reading Hospital - Tower Health, West Reading, PA, USA
| | - Asad Jehangir
- Department of Gastroenterology, Temple University, Philadelphia, PA, USA
| |
Collapse
|
7
|
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
|
8
|
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
|