A 64-Year-Old Woman With Recurrent Gastrointestinal Bleeding

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

Disclosures

March 31, 2016

Endoscopic management has become the standard approach for the treatment of Dieulafoy lesions. Several modalities, alone or in combination, are used to control the bleeding. These include injection of epinephrine or a sclerosing agent; hemoclip placement; monopolar, bipolar, heater probe, and argon electrocoagulation; and laser photocoagulation. Endoscopic success rates are reported to be as high as 90%-95%. Endoscopic Doppler ultrasonography has been used to confirm ablation of a Dieulafoy lesion by documenting the absence of blood flow after injection therapy.[4,11]

Surgical intervention is reserved for cases in which endoscopic treatment is unsuccessful or the patient has rebleeding despite endoscopic treatment. Wedge resection is preferred to simple oversewing of the lesion by the surgeon because of high rebleeding rates. A combined endoscopic and laparoscopic approach has been described; this approach allows precise location of the aberrant vessel with intraoperative endoscopy, followed by limited laparoscopic surgical resection.

Angiography and embolization is another modality that has been reported in patients with active bleeding who are not amenable to endoscopic therapy.

The possibility of identifying patients at risk for Dieulafoy lesions is still uncertain. In at least a subset of patients, mucosal injury may unmask caliber-persistent arteries. In other groups of patients, ischemia resulting from decreased perfusion or oxygenation may play a role.

In this case, the patient was treated with hemoclips because of the large caliber of the vessel; three hemoclips (Figure 3) obliterated the lesion, and no active bleeding was seen after flushing.

The patient was discharged on the fourth day after treatment, without any complications. The patient remained well at 2 months after treatment; her hemoglobin was stable at approximately 10 g/dL, without signs or symptoms of hemorrhagic diathesis.

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