What is a Dieulafoy Lesion on Endoscopy
A Dieulafoy lesion is a tortuous submucosal artery that penetrates through the mucosa of the gastrointestinal tract, causing potentially massive hemorrhage from a tiny mucosal defect without underlying ulceration. 1
Endoscopic Appearance and Location
Classic Features
- The lesion appears as an arteriole protruding through a small mucosal defect, typically without surrounding ulceration or significant mucosal abnormality 2
- The vessel is usually 1-3 mm in diameter and may be actively spurting blood or show a visible vessel in the absence of active bleeding 1
- The surrounding mucosa appears normal or near-normal, which makes the lesion particularly difficult to identify 2, 3
Typical Locations
- Most commonly found in the stomach (53% of cases), usually within 6 cm of the gastroesophageal junction on the lesser curve 2, 4
- Duodenum and jejunum account for 33% of cases 4
- Large intestine represents 13% of cases 4
- Can occur in the esophagus, though this is rare 5
Diagnostic Challenges
Why It's Difficult to Diagnose
- The lesion's small size and hidden location make it a diagnostic challenge, often requiring repeated endoscopy if initial examination is negative 1, 2
- The normal-appearing surrounding mucosa can cause the lesion to be overlooked during routine endoscopy 6, 3
- Intermittent bleeding patterns may result in the lesion being obscured by blood or appearing inactive during examination 3
Commonly Missed Scenarios
- Dieulafoy lesions are among the most frequently missed lesions in the upper gastrointestinal tract, along with Cameron's erosions, fundic varices, and angiectasias 7
- Younger patients are more likely to have Dieulafoy lesions as a cause of bleeding compared to older patients 7
Clinical Significance
Presentation
- Patients typically present with hematemesis, melena, hematochezia, or anemia, often with rapid blood loss requiring urgent intervention 4, 3
- The bleeding can be massive and life-threatening despite the small size of the mucosal defect 6, 5
- Mean age at presentation is approximately 58-79 years, with males more frequently affected 4, 3
Mortality Risk
- Dieulafoy lesions are associated with very high mortality rates if not promptly identified and treated 8
- Overall mortality ranges from 10-17%, though death directly attributable to exsanguination from the lesion occurs in a minority of cases 4, 3
- Most deaths are related to underlying comorbidities rather than the bleeding itself 3
Imaging Characteristics
CT Angiography Findings
- CTA can demonstrate Dieulafoy lesions, which are most conspicuous on arterial phase imaging 8, 1
- Multiphase CT enterography may be helpful when the lesion is beyond the reach of standard endoscopy 1
- CTA is particularly useful in hemodynamically unstable patients or when endoscopy fails to localize the bleeding source 1