Makindo Medical Notes

Related Subjects: |Upper Gastrointestinal Bleed |Oesophageal Variceal Bleeding |Dieulafoy Lesion |Mallory-Weiss Tear |Gastric Cancer |Peptic Ulcer Disease |Oesophagogastroduodenoscopy (OGD/EGD) |Hereditary Haemorrhagic Telangiectasia |Hypovolaemic or Haemorrhagic Shock

It accounts for 1–2% of acute gastrointestinal (GI) bleeding, but arguably is under-recognised rather than rare

Endoscopic view
Misplaced vessel poking through
Only fools forget
Pumping stomach fundus bleed
Scope now, need of urgent speed
@DrCindyCooper

About

• Georges Dieulafoy in 1898 documented fatal UGIB in three asymptomatic young men
• A cause of 1-2% upper Gastrointestinal bleeding. The bleeding is arterial.

Aetiology

• Histologically normal vessel that has an abnormally large diameter
• It has maintained a constant width of 1–3 mm
• Aberrant, dilated, submucosal blood vessel. Bleeding can be severe

Typical patient profile presenting with Dieulafoy's lesion

• Elderly (M:F = 2:1)
• Multiple co-morbidities
• Often already hospitalised
• Often on NSAIDs, aspirin and warfarin
• Presents with massive GI bleeding which might be recurrent
• No previous history of GI pathology

Clinical

• Recurrent massive UGI Bleeds can occur
• Haematemesis /Melaena, shock or iron deficiency anaemia

Investigations

• FBC: anaemia, U&E elevated urea with UGIB, Clotting screen
• OGD: Lesion seen in bleeding patient in the upper stomach, lesser curvature. There may be active arterial spurting or micropulsatile streaming from a mucosal defect < 3 mm or through normal surrounding mucosa. Visualisation of protruding vessel with or without bleeding, within a minute mucosal defect or through normal surrounding mucosa. The appearance of fresh, densely adherent clot with a narrow point of attachment to a minute mucosal defect or to normal appearing mucosa
• Angiography: after failed OGD. look for a tortuous and ectactic artery usually in the territory of the left gastric artery lacking early venous return is suggestive.
• Red cell scanning: can help locate a bleeding Dieulafoy's lesion when endoscopy had failed.

Management

• ABC, resuscitation, Consider immediate endoscopy, haemostatic intervention
• Endoscopy: Endoscopic haemostatic procedures can be classified into three groups: (i) thermal – electrocoagulation, heat probe coagulation and argon plasma coagulation; (ii) regional injection – local epinephrine injection and sclerotherapy; and (iii) mechanical – banding and haemoclip
• Endoscopic ultrasound (EUS) may help detection of the aberrant vessel in the submucosa. It also can confirm ablation of a Dieulafoy's lesion after injection therapy or elastic band ligation by confirming absence of blood flow
• Reverse anticoagulation and stop antiplatelets
• Angiography and embolisation is a valuable alternative to endoscopy for inaccessible lesions. There is a risk of causing ischaemia and damage.
• Surgical intervention is kept for failure of therapeutic endoscopic or angiographic interventions and it should be guided by pre-operative localisation. Surgical procedures currently employed include under-running of the lesion or a wedge resection of the affected section of gut

References

• Dieulafoy Lesion