What is the immediate management for a patient with a Dieulafoy's lesion?

Immediate Management of Dieulafoy's Lesion

Aggressive volume resuscitation with crystalloids and hemodynamic stabilization must be achieved first, followed by urgent upper endoscopy within 24 hours, with endoscopic mechanical therapy (hemoclips or band ligation) as the first-line definitive treatment. 1, 2

Initial Resuscitation and Stabilization

Hemodynamic stabilization takes absolute priority before attempting to identify or treat the bleeding source. 1

• Place two large-bore IV catheters and initiate rapid infusion of normal saline to restore end-organ perfusion and stabilize vital signs 1, 2
• Transfuse red blood cells when hemoglobin falls below 80 g/L in patients without cardiovascular disease 2
• Use a higher hemoglobin threshold (typically <100 g/L) for transfusion in patients with underlying cardiovascular disease or severe acute bleeding 1, 2
• Begin IV proton pump inhibitor therapy immediately upon presentation with an 80 mg bolus followed by 8 mg/hour continuous infusion before endoscopy 2

Diagnostic Approach

Upper endoscopy should be performed within 24 hours after initial resuscitation as the first diagnostic study. 3, 1, 2

• In hemodynamically unstable patients with suspected active bleeding despite resuscitation, consider CT angiography as a first-line study to localize the bleeding source 1
• Be prepared for diagnostic challenges: Dieulafoy lesions appear as a small (1-3 mm) mucosal defect with a protruding arteriole that may be actively spurting or show a visible vessel 4
• Repeated endoscopy may be necessary if initial examination is negative, as these lesions are among the most frequently missed causes of upper GI bleeding due to their small size 4
• Multiphase CT enterography with arterial phase imaging can help detect lesions beyond the reach of standard endoscopy 1, 4

Endoscopic Treatment

Endoscopic mechanical therapy with either hemoclips or band ligation is the first-line treatment and superior to injection therapy alone. 1, 5, 6

Mechanical Therapy (Preferred)

• Hemoclips are particularly useful for actively bleeding large vessels and achieve initial hemostasis in 91.7% of cases with significantly lower rebleeding rates (8.3%) compared to injection therapy 1, 6
• Band ligation has similar efficacy to hemoclipping with initial hemostasis rates of 100% and minimal early rebleeding 1, 7
• Mechanical therapies require fewer therapeutic sessions (average 1.17 sessions) to achieve permanent hemostasis compared to injection methods 6

Combination Therapy

• If mechanical therapy alone is insufficient, combine epinephrine injection with thermal methods (heater probe or bipolar electrocoagulation) for active arterial bleeding 1, 5
• Epinephrine injection alone has higher rebleeding rates (33.3%) and should not be used as monotherapy 6, 8
• Combination therapy is superior to monotherapy due to lower recurrent bleeding rates 5

Post-Endoscopic Management

Continue high-dose IV PPI therapy for 72 hours after successful endoscopic hemostasis. 1, 2

• Administer 80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours 2
• Transition to oral PPI twice daily for 14 days after completing IV therapy, then once daily thereafter 2
• Hospitalize patients for at least 72 hours after endoscopic hemostasis with continuous monitoring of vital signs including pulse, blood pressure, and urine output 1, 2
• Patients who remain hemodynamically stable 4-6 hours after endoscopy can begin oral intake 1

Management of Rebleeding

Attempt repeat endoscopic therapy as the first approach for rebleeding. 2

• Early rebleeding (within 72 hours) occurs in approximately 8-33% of cases depending on the initial treatment modality used 7, 6
• Obtain surgical consultation for patients in whom repeat endoscopic therapy fails 2
• For lesions in the small intestine beyond standard endoscopic reach, consider deep enteroscopy or intraoperative enteroscopy 1

Special Considerations

• Dieulafoy lesions carry mortality rates of 10-17% if not promptly identified and treated, though advances in endoscopic techniques have reduced mortality from historical rates of 80% to approximately 8% 4, 5
• Do not delay endoscopy in patients receiving anticoagulants (warfarin or DOACs); proceed with endoscopy and hemostatic therapy as indicated 2
• In patients with recurrent bleeding, evaluate for underlying coagulopathies or anticoagulant medication use 1
• Surgical intervention is now reserved only for cases that fail both therapeutic endoscopic and angiographic interventions 5