Management of Dieulafoy's Lesion
Endoscopic mechanical therapy with either band ligation or hemoclipping is the first-line treatment for Dieulafoy's lesion, with success rates of 75-100%. 1, 2
Initial Management
- Aggressive volume resuscitation and hemodynamic stabilization are the first priorities before attempting definitive treatment 1
- Place two large-bore IV catheters and infuse normal saline to stabilize vital signs 1
- Blood transfusion is indicated for severe bleeding or when hemoglobin is less than 100 g/L 1
Diagnostic Approach
- Upper endoscopy should be performed as the first diagnostic study after resuscitation 1
- Dieulafoy lesions can be difficult to diagnose and may require repeated endoscopy if initial examination is negative 1
- CT angiography should be considered as a first-line study in hemodynamically unstable patients with suspected active bleeding 1
- Multiphase CT enterography can help detect Dieulafoy lesions, which are most conspicuous on arterial phase imaging 1
Endoscopic Treatment Options
First-Line Treatment:
Alternative Options:
- Injection therapy (epinephrine, hypertonic saline-epinephrine, or pure ethanol) can achieve initial hemostasis but has higher rebleeding rates when used alone 1, 2
- Thermal methods (heater probe) may be used in combination with injection therapy 4, 5
- Combination therapy is superior to monotherapy due to lower rates of recurrent bleeding 2
Treatment Success Rates
- Initial hemostasis can be achieved in 100% of cases with appropriate endoscopic therapy 4, 3
- Rebleeding rates are low (0-5%) with mechanical methods 3, 6
- Long-term outcomes are favorable with endoscopic management, with studies showing no recurrence during follow-up periods of 28-47 months 3, 6
Post-Treatment Management
- High-dose proton pump inhibitor therapy is recommended after successful endoscopic therapy 1
- Close monitoring of vital signs, including continuous observation of pulse, blood pressure, and urine output 1
- Patients who are hemodynamically stable 4-6 hours after endoscopy can begin oral intake 1
Management of Refractory Cases
- For persistent or recurrent bleeding despite initial endoscopic therapy, repeat endoscopic treatment should be attempted 1, 6
- Angiographic embolization should be considered for cases that fail repeated endoscopic therapy 1, 2
- Surgical intervention is reserved for cases that fail both endoscopic and angiographic interventions 2
Special Considerations
- For Dieulafoy lesions in the small intestine beyond the reach of standard endoscopy, deep enteroscopy or intraoperative enteroscopy may be required 1
- In patients with recurrent bleeding, consider underlying coagulopathies or use of anticoagulant medications 1
- Advances in endoscopic techniques have reduced mortality in patients with Dieulafoy's lesion from 80% to 8% 2