From the Guidelines
The management of Dieulafoy's lesion causing gastrointestinal bleeding primarily involves endoscopic intervention as the first-line treatment. When a patient presents with suspected Dieulafoy's lesion bleeding, urgent endoscopy should be performed to locate and treat the lesion. Endoscopic treatment options include thermal coagulation, mechanical methods like hemoclipping, or combination therapy. According to the guidelines for non-variceal upper gastrointestinal haemorrhage 1, endoscopic therapy is effective in reducing rebleeding, need for surgical intervention, and mortality. Endoscopic band ligation is also effective, with success rates exceeding 90%.
Some key points to consider in the management of Dieulafoy's lesion include:
- The lesion is often difficult to diagnose and treat, but endoscopic modalities such as band ligation, injection, and thermal methods have been shown to be effective 1.
- If endoscopic management fails after 2-3 attempts, angiographic embolization should be considered as the next step, involving selective catheterization of the bleeding vessel and embolization with materials such as gelfoam or coils 1.
- Surgery is reserved for cases where both endoscopic and angiographic approaches fail, typically involving wedge resection of the affected area.
- Following successful hemostasis, patients should receive proton pump inhibitors to prevent rebleeding.
It's worth noting that Dieulafoy's lesion is not a true arteriovenous malformation but rather a large, tortuous submucosal artery that erodes through the overlying mucosa without preceding ulceration, causing potentially massive bleeding. The lesion most commonly occurs in the proximal stomach but can be found throughout the gastrointestinal tract. Rebleeding occurs in approximately 10% of cases, necessitating close monitoring after initial treatment.
From the Research
Overview of Dieulafoy's Lesion
- Dieulafoy's lesion is a rare but potentially life-threatening source of gastrointestinal (GI) hemorrhage, responsible for roughly 1%-6.5% of all cases of acute non-variceal GI bleeding 2.
- It involves an aberrant arteriole eroding the gastric mucosa, resulting in severe, recurrent bleeding that poses diagnostic and management challenges 3.
Clinical Presentation
- Dieulafoy's lesions typically present with severe, active, gastrointestinal bleeding, without prior symptoms, often causing hemodynamic instability and requiring transfusion of multiple units of packed erythrocytes 4.
- The mean age of presentation is 66±17 years, with 54% of cases reported in males, and major underlying disorders include hypertension, diabetes mellitus, and chronic kidney disease 5.
Diagnosis
- Endoscopy is the first diagnostic test, but has only a 70% diagnostic yield because the lesions are frequently small and inconspicuous 4.
- The average number of colonoscopies required for the diagnosis of rectal Dieulafoy's lesion is 1.5±0.7 5.
Management
- Endoscopic therapy, including clips, sclerotherapy, argon plasma coagulation, thermocoagulation, or electrocoagulation, is the recommended initial therapy, with primary hemostasis achieved in nearly 90% of cases 4.
- Dual endoscopic therapy of epinephrine injection followed by ablative or mechanical therapy appears to be effective, and mechanical hemostasis methods during endoscopy are effective, with recurrence rates of 8-10% 3.
- Surgical intervention is reserved for severe, uncontrolled cases, and advances in endoscopy have increased the detection of Dieulafoy's lesions and decreased the mortality from 80% to 8.6% 6.
Treatment Outcomes
- The primary hemostasis rate for endoscopic treatment is 88%, and the overall mortality rate is 6%, with causes of death unrelated to Dieulafoy's lesion 5.
- Prompt diagnosis and appropriate management are of paramount importance to prevent serious hemodynamic complications, and the best therapeutic modality remains to be determined, but mechanical endoscopic methods are safe and effective 5.