Diagnosis & Discussion

Diagnosis

Ruptured Dieulafoy lesion.

Discussion

Eponymously named after the 19th-century French surgeon Georges Dieulafoy, the Dieulafoy lesion (DL) is a large tortuous submucosal artery. Erosion through the overlying mucosa causes potentially life-threatening hematemesis and/or melena. Symptomatic DL is the cause of 1-2% of acute gastrointestinal hemorrhage. However, many cases of DL go unrecognized, as they are asymptomatic (Figures 2 and 3). DL is two times more common in males than in females. The typical patient is elderly with multiple comorbidities like alcoholism, cardiopulmonary disease, chronic kidney disease, diabetes mellitus, and liver failure. At the time of presentation, many patients are hospitalized and on "blood thinning" medications like non-steroidal anti-inflammatory drugs and warfarin.

DL occurs in the stomach (80%), duodenum (15%), colon and rectum (5%), esophagus (1%), jejunum (1%), and the anal canal. Rare extra-alimentary DLs have been identified in the gallbladder and bronchus. The DL vessel is histologically normal and may represent an anatomic variant. The mechanisms that cause rupture of the artery remain unknown, but leading hypotheses include ischemic necrosis of the thin overlying mucosa caused by arterial pulsations, stercoral ulceration, and age-related mucosal atrophy.

Diagnosis is usually made at endoscopy in symptomatic patients, where a bleeding vessel or an adherent blood clot surrounded by normal mucosa is seen. DL can also be diagnosed by wireless capsule endoscopy, angiography, and Technetium-99m labeled red blood cell scanning. Treatment is by endoscopic hemostatic techniques like injection sclerotherapy, local epinephrine injections, laser photocoagulation, banding, and hemoclipping. Inaccessible lesions can be treated with angiographic embolization. Surgery is used as a last resort when less invasive interventions are unsuccessful. Mortality is about 8.6%, mainly attributed to the patient’s advanced age or preexisting medical condition(s).

References

Baxter M, Aly EH. Dieulafoy's lesion: current trends in diagnosis and management. Ann R Coll Surg Engl. 2010;92(7):548-554. doi:10.1308/003588410X12699663905311

Lee YT, Walmsley RS, Leong RW, Sung JJ. Dieulafoy's lesion. Gastrointest Endosc. 2003;58(2):236-243. doi:10.1067/mge.2003.328

Polydorides AD. Dieulafoy lesion in: Greenson J K, Lauwers GY, Montgomery EA, Owens SR, et al. (editors). Diagnostic Pathology: Gastrointestinal. Elsevier, Philadelphia, 2016.

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