Dieulafoy's lesion

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Dieulafoy's lesion
Other namesExulceratio simplex Dieulafoy
epinephrine injection, etc
Prognosis8% mortality[1]
Frequency1.5% of gastrointestinal bleeding

Dieulafoy's lesion (French:

gastrointestinal bleeds in adults. It was named after French surgeon Paul Georges Dieulafoy, who described this condition in his paper "Exulceratio simplex: Leçons 1-3" in 1898.[5][6] It is also called "caliber-persistent artery" or "aneurysm" of gastric vessels. However, unlike most other aneurysms
, these are thought to be developmental malformations rather than degenerative changes.

Signs and symptoms

Dieulafoy's lesion often do not cause symptoms (asymptomatic). When present, symptoms usually relate to painless bleeding, with vomiting blood (

iron deficiency anemia
. Usually, there are no gastrointestinal symptoms that precede the bleeding (abdominal pain, nausea, etc.).

Presenting Symptoms
Recurrent hematemesis with melena 51% of cases
Hematemesis without melena 28% of cases
Melena without hematemesis 18% of cases

Though exceptionally rare, cases of Dieulafoy lesions occurring in the gallbladder can cause upper abdominal pain, which is usually right upper quadrant or upper middle (

epigastric).[7] Though gallbladder Dieulafoy lesions usually occur with anemia (83%), they generally do not cause overt bleeding (hematochezia, hematemesis, melena, etc.).[7]

Cause

In contrast to peptic ulcer disease, a history of

NSAID
use is usually absent in Dieulafoy's lesion.

Pathophysiology

Dieulafoy lesions are characterized by a single abnormally large blood vessel (arteriole) beneath the gastrointestinal mucosa (submucosa) that bleeds,[8] in the absence of any ulcer, erosion, or other abnormality in the mucosa. The size of these blood vessels varies from 1–5 mm (more than 10 times the normal diameter of mucosal capillaries). Pulsation from the enlarged vessels leads to focal pressure that causes thinning of the mucosa at that location, leading to exposure of the vessel and subsequent hemorrhage.[1]

Approximately 75% of Dieulafoy's lesions occur in the upper part of the stomach within 6 cm of the

anastamoses (5%), the jejunum (1%) and the esophagus (1%).[9]
Dieulafoy's lesions have been reported in the gallbladder. The pathology in these extragastric locations is essentially the same as that of the more common gastric lesion.

Diagnosis

A Dieulafoy's lesion is difficult to diagnose, because of the intermittent pattern of bleeding. Dieulafoy's lesion are typically diagnosed during endoscopic evaluation, usually during

terminal ileum) may be diagnosed during colonoscopy. Dieulafoy's lesions are not easily recognized and therefore multiple evaluations with endoscopy may be necessary. Once identified during endoscopy, the mucosa near a Dieulafoy's lesion may be injected with ink. Tattooing the area can aid in identifying the location of the Dieulafoy's lesion in the event of rebleeding.[1] Endoscopic ultrasound
has been used both to facilitate identification of Dieulafoy lesions and confirm the treatment success.

bowel preparation
.

Treatment

In most cases, Dieulafoy lesions are treated with endoscopic interventions. Endoscopic techniques used in the treatment include

hemoclipping or banding
.

In cases of refractory bleeding, interventional radiology may be consulted for an angiogram with subselective embolization.[10]

Prognosis

The mortality rate for Dieulafoy's was much higher before the era of endoscopy, where open surgery was the only treatment option. Mortality has decreased from 80% to 8% as a result of endoscopic therapies.[1] Long term control of bleeding (hemostasis) is achieved in 85 - 90 percent of cases.

Epidemiology

Dieulafoy's lesions account for roughly 1.5 percent of gastrointestinal hemorrhage.[11] These lesions are twice as common in men, and often occur in older individuals (over 50 years of age) with multiple comorbidities, including hypertension, cardiovascular disease, chronic kidney disease, and diabetes. Dieulafoy's lesions present in individuals with an average age of 52 years.[1]

History

Dieulafoy's lesion was first described in 1884 by M.T. Gallard.[11] The lesion was named after French surgeon Paul Georges Dieulafoy, who described the condition in his paper "Exulceratio simplex: Leçons 1-3" in 1898.[11][5][6] Dieulafoy believed (incorrectly) the bleeding from this lesion was due to erosions of the mucosa in the stomach.[11]

References

  1. ^
    ISBN 0323609627
    .
  2. ISSN 0003-4932
    .
  3. ^
    PMID 10453143
    .
  4. PMID 17237996
    .
  5. ^
    Who Named It?
  6. ^ a b G. Dieulafoy. Exulceratio simplex: Leçons 1-3. In: G. Dieulafoy, editor: Clinique medicale de l'Hotel Dieu de Paris. Paris, Masson et Cie: 1898:1-38.
  7. ^
    PMID 29477106
    .
  8. PMID 2210260
    .
  9. PMID 12872092
    .
  10. PMID 23997409
    .
  11. ^
    PMID 28062437
    .

External links

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