What is the management approach for a patient with a Dieulafoy lesion?

Management of Dieulafoy Lesion

Endoscopic mechanical therapy, particularly band ligation or hemoclipping, is the first-line treatment for Dieulafoy lesions due to superior hemostasis rates and lower rebleeding compared to injection therapy alone. 1, 2

Definition and Epidemiology

• Dieulafoy lesion is a tortuous submucosal artery in the GI tract that penetrates through the mucosa over time, causing gastrointestinal bleeding 3
• It accounts for 1-2% of cases of acute upper gastrointestinal bleeding 4
• Most commonly found in the proximal stomach, up to 6 cm from the gastroesophageal junction, but can occur anywhere in the GI tract 1

Initial Management

• Aggressive volume resuscitation and maintenance of hemodynamic stability are the first priorities before attempting to identify and treat the source of hemorrhage 3, 5
• For patients with significant bleeding, place two large-bore IV catheters and infuse normal saline to stabilize vital signs 5
• Transfuse blood when bleeding is severe (evidenced by hematemesis and/or shock) or when hemoglobin is less than 100 g/L in acute bleeding 5

Diagnostic Approach

• Upper endoscopy (esophagogastroduodenoscopy) should be performed as the first diagnostic study after resuscitation 3
• In hemodynamically unstable patients with suspected active bleeding, CT angiography (CTA) could be considered as a first-line study 3
• Dieulafoy lesion can be difficult to diagnose and may require repeated endoscopy if initial examination is negative 3
• Multiphase CT enterography can help detect Dieulafoy lesions, which are most conspicuous on arterial phase imaging 3

Endoscopic Treatment Options

• Mechanical methods:

  • Endoscopic band ligation has shown superior outcomes with significantly lower rebleeding rates (0-8.3%) compared to injection therapy (33-75%) 1, 2
  • Hemoclips are particularly useful for actively bleeding large vessels and have similar efficacy to band ligation 3, 2

• Injection methods:

  • Epinephrine (adrenaline) injection can achieve initial hemostasis but has higher rebleeding rates when used alone 3, 6
  • Combination therapy (injection plus thermal methods) may be more effective than injection alone for active arterial bleeding 3

• Thermal methods:

  • Heater probe or multipolar coagulation can be effective, especially when combined with injection therapy 3
  • Argon Plasma Coagulator has shown effectiveness in some cases 3

Treatment Algorithm

1. First-line treatment: Endoscopic mechanical therapy with either:

   • Band ligation (preferred in most cases) 1, 7
   • Hemoclipping (particularly for actively bleeding vessels) 3, 2

2. Alternative approach: Combination therapy

   • Epinephrine injection followed by thermal therapy (heater probe or multipolar coagulation) 3

3. For refractory bleeding:

   • Repeat endoscopic therapy 5
   • If endoscopic treatment fails, consider angiographic embolization 4
   • Surgical intervention as last resort when endoscopic and angiographic interventions fail 4

Post-Treatment Management

• High-dose proton pump inhibitor therapy (80 mg stat followed by 8 mg/hour infusion for 72 hours) after successful endoscopic therapy 3
• Close monitoring of vital signs, including continuous observation of pulse, blood pressure, and urine output 5
• Patients who are hemodynamically stable 4-6 hours after endoscopy can begin oral intake 5

Outcomes and Prognosis

• Advances in endoscopic techniques have reduced mortality in patients with Dieulafoy's lesion from 80% to 8% 4
• Mechanical therapies have significantly reduced the need for surgical intervention 1, 4
• Initial hemostasis success rates with endoscopic therapy range from 75% to 100% 4
• Rebleeding rates are significantly lower with mechanical methods (8.3%) compared to injection therapy (33.3%) 2

Special Considerations

• For Dieulafoy lesions in the small intestine beyond the reach of standard endoscopy, deep enteroscopy or intraoperative enteroscopy may be required 3
• In patients with recurrent bleeding from Dieulafoy lesions, consider testing for underlying coagulopathies or use of anticoagulant medications 5