What is the management approach for a patient presenting with a Dileulafoy lesion and significant gastrointestinal bleeding?

Management of Dieulafoy Lesion with Significant GI Bleeding

Immediately initiate aggressive volume resuscitation with two large-bore IV catheters and normal saline to achieve hemodynamic stability before any diagnostic workup, then proceed directly to upper endoscopy for both diagnosis and therapeutic intervention. 1, 2

Initial Resuscitation and Stabilization

• Establish two large-bore IV lines and begin aggressive fluid resuscitation with normal saline as the absolute first priority, even before attempting to identify the bleeding source 1, 2
• Transfuse packed red blood cells when hemoglobin falls below 100 g/L in acute bleeding or when bleeding is severe 2
• Monitor vital signs continuously, including pulse, blood pressure, and urine output 2
• Calculate the shock index (heart rate ÷ systolic blood pressure) immediately—values >1 indicate unstable bleeding requiring ICU admission 3

Diagnostic Approach

Upper endoscopy (EGD) is the mandatory first diagnostic test after hemodynamic stabilization, successfully identifying the bleeding source in 95% of cases 1. This is critical because:

• Dieulafoy lesions account for 1-2% of acute upper GI bleeding but cause severe, life-threatening hemorrhage 1, 4
• The lesion appears as a pigmented protuberance from an exposed vessel stump with minimal surrounding erosion and no ulceration (visible vessel sans ulcer) 4
• 75% of Dieulafoy lesions occur in the stomach, predominantly within 6 cm of the gastroesophageal junction along the lesser curve 4
• Initial endoscopy has only a 70% diagnostic yield because lesions are frequently small and inconspicuous—repeated endoscopy may be necessary if initial examination is negative 2, 4

For hemodynamically unstable patients with suspected active bleeding where endoscopy may be delayed, CT angiography can be considered as a first-line study, with Dieulafoy lesions most conspicuous on arterial phase imaging 2.

Endoscopic Treatment Strategy

Dual endoscopic therapy combining epinephrine injection followed by mechanical therapy (hemoclipping or band ligation) is the recommended first-line treatment, achieving primary hemostasis in nearly 90% of cases 2, 4, 5:

Preferred Mechanical Options:

• Hemoclipping is particularly effective for actively bleeding large vessels, with initial success rates of 84.6% and excellent long-term outcomes with no rebleeding in 95-100% of patients during follow-up 2, 5, 6
• Band ligation has similar efficacy to hemoclipping but carries a small risk of perforation from banding deep mural tissue 4

Injection and Thermal Therapies:

• Epinephrine injection alone achieves initial hemostasis but has higher rebleeding rates when used as monotherapy 2
• Combination therapy with injection plus thermal methods (heater probe, argon plasma coagulation, electrocoagulation) is more effective than injection alone for active arterial bleeding 2, 7
• Sclerotherapy with polidocanol combined with norepinephrine injection achieved successful management in 96.4% of patients in one series 7

The key principle is that dual therapy (injection plus mechanical or thermal) outperforms single-modality treatment 2, 4.

Post-Endoscopic Management

• Administer high-dose proton pump inhibitor therapy after successful endoscopic hemostasis 2
• Continue close monitoring of vital signs for at least 4-6 hours post-procedure 2
• Patients who remain hemodynamically stable 4-6 hours after endoscopy can begin oral intake 2
• Emergency endoscopy is indicated for persistent hemorrhage causing vital sign deviations or requiring repeated transfusions 1
• When performed within 24 hours of admission, endoscopy effectively reduces transfusion requirements and shortens hospital stays 1

Management of Failed Endoscopic Therapy

If initial endoscopic therapy fails (occurs in approximately 10-15% of cases):

1. Attempt repeat endoscopic therapy first—additional endoscopic sessions achieve hemostasis in an additional 11.5% of cases 5, 6
2. Consider angiographic embolization as second-line therapy 4
3. Surgical wedge resection is reserved for uncontrollable bleeding after failed endoscopic and angiographic attempts 4, 7, 5

Special Considerations for Extragastric Lesions

• For Dieulafoy lesions in the jejunum or ileum beyond standard endoscopic reach, deep enteroscopy or intraoperative enteroscopy may be required to localize and treat the lesion 2, 8
• Video capsule endoscopy has diagnostic yields of 87-91.9% when performed within 48 hours of bleeding but drops below 50% if delayed beyond 3 days 1
• Lesions in the duodenum, esophagus, and colorectum are increasingly recognized and require similar endoscopic management approaches 4

Critical Pitfalls to Avoid

• Never delay resuscitation to pursue diagnostic studies—this is the most critical error that increases mortality 1, 2
• Do not assume GI bleeding has ceased spontaneously without endoscopic confirmation, even though 75% of upper GI bleeding stops spontaneously 1
• Evaluate for underlying coagulopathies or anticoagulant use in patients with recurrent bleeding from Dieulafoy lesions 2
• Do not rely on nasogastric aspirate alone, as 3-16% of patients with upper GI bleeding have negative aspirates 1

Outcomes and Prognosis

With aggressive endoscopic therapy, mortality from Dieulafoy lesions has declined from approximately 30% in the 1970s to 9-13% currently 4. Long-term outcomes after successful endoscopic treatment are excellent, with 95-100% of patients experiencing no recurrence of bleeding during mean follow-up periods of 28-47 months 7, 5, 6.