A 64-Year-Old Woman With Recurrent Gastrointestinal Bleeding

Juan Carlos Munoz, MD; Matthew S. Cole, MD, MPH

Disclosures

March 31, 2016

The etiology of Dieulafoy lesions is unknown. It was originally thought that Dieulafoy lesions were caused by an aneurysm in one of the vessels within the gastric wall, perhaps in combination with atherosclerosis. It has also been suggested that a congenital or acquired vascular malformation might be the underlying cause. The consensus, however, seems to be that it is caused by an abnormally large-caliber persistent tortuous submucosal artery.

Events that can trigger bleeding are also not well understood. Patients who bleed from Dieulafoy lesions are typically men (the male-to-female ratio is 2:1) who have multiple comorbidities, including cardiovascular disease, hypertension, chronic kidney disease, and diabetes. In the setting of gastrointestinal bleeding caused by Dieulafoy lesions, a history of alcohol abuse or NSAID use is generally absent. The most common presenting symptom is recurrent hematemesis with melena, which is present in 51% of cases; hematemesis without melena is present in 28% of cases, and melena alone is seen in 18%.

Patients with lesions in the middle or distal jejunum, right colon, left colon, and rectum may present with only hematochezia in 3% of cases. Bleeding is often self-limited, although it is usually recurrent and can be profuse. Because of the small size of the lesion and the normal surrounding mucosa, the diagnosis of a Dieulafoy lesion can be made with confidence just after or during active bleeding in an area without an associated ulcer or mass lesion. An initial evaluation may reveal hemodynamic instability, postural hypotension, and profound anemia.

Various radiologic (eg, small-bowel enteroclysis, tagged red blood cell scan, mesenteric angiography) and endoscopic modalities (eg, upper endoscopy; colonoscopy; push enteroscopy; single-balloon enteroscopy; double-balloon enteroscopy; and, most recently, capsule endoscopy) have been used to localize the lesion in the gastrointestinal tract. Video capsule endoscopy (VCE, also known as "wireless capsule endoscopy") has a diagnostic yield of 60%-80% in patients with obscure gastrointestinal bleeding. In head-to-head comparisons, the yield of VCE is superior to that of push enteroscopy, small-bowel enteroclysis, and mesenteric angiography. No reliable data currently exist comparing VCE with double-balloon enteroscopy devices.[7,8,9,10]

At present, the diagnosis is usually made by endoscopy. Repeat endoscopies are sometimes necessary. Approximately 49% of lesions are identified during the initial endoscopic examination, whereas 33% require more than one endoscopic evaluation (including push, single-balloon, or double-balloon enteroscopy or VCE) for confident identification.

The remaining patients require angiographic identification of the Dieulafoy lesions. In some series, however, identification of the lesions was more accurate at the initial endoscopic examination, because Dieulafoy lesions were identified in as many as 95% of cases. This was attributed to the fact that endoscopy was generally performed within the first 2 hours after admission of the patient, allowing recognition of actively bleeding lesions. This might also, however, reflect the increased awareness of the existence of a Dieulafoy lesion and the experience of the endoscopist.

The endoscopic appearance of Dieulafoy lesions varies, and it may consist of active arterial spurting, a protruding vessel without active bleeding, or fresh adherent clots. The risk for rebleeding after endoscopic therapy ranges from 9% to 40% in various reports. Endoscopic tattooing with India ink injections has been very helpful for locating the lesion for endoscopic retreatment or intraoperative surgical intervention.[4,6,8,10,11]

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