Introduction
Dieulafoy’s lesion is rare but is a potentially life-threatening condition. It causes one to two percent of acute gastrointestinal bleeding but is always left unrecognized. It is severe and is included in differential diagnoses of obscure gastrointestinal bleeding. Dieulafoy’s lesions are commonly located in the stomach, and they are also detected in the duodenum. Gastric Dieulafoy’s lesions are detected using an endoscopy. The prognosis of the lesion is always poor, with a mortality rate ranging from 23 percent to 79 percent.
What Is Dieulafoy Lesion?
Dieulafoy lesion is a condition leading to an abnormally large artery. These arteries usually are vessel that carries blood from the heart to other areas of the body and the lining of the gastrointestinal system. Most commonly occurs in located in the stomach and also small and large intestines. This leads to severe and sudden gastrointestinal bleeding and also presents in individuals affected by blood pressure problems.
What Are the Signs and Symptoms of Dieulafoy Lesion?
Dieulafoy’s lesion often causes no symptoms, and they are asymptomatic. When they exhibit symptoms, they usually relate to black stools and vomiting blood. Dieulofay’s lesion may cause rectal bleeding or, rarely, iron deficiency anemia. Other symptoms associated with abdominal pain, nausea, and vomiting.
The division of symptoms is based on the following:
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Recurrent hematemesis with melena - 51 percent of cases.
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Hematemesis without melena - 28 percent of cases.
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Melena without hematemesis - 18 percent of cases.
Dieulofy’s disease mostly occurs in the gallbladder and is the reason for upper abdominal pain and epigastric pain. They usually occur with anemia in 83 percent of cases. Dieulafoy generally does not cause over bleeding.
How Is Diagnosis Made for Dieulafoy Lesion?
Dieulafoy’s lesion is typically present acutely or with massive hemorrhage. Other investigations of the condition include the following:
Endoscopy: Gastrointestinal endoscopy is effective in diagnosing the lesion upto 70 percent. The use of endoscopic ultrasound also helps in endoscopic diagnosis. Other methods, such as push enteroscopy, are an extension of upper gastrointestinal endoscopy. Wireless capsule endoscopy is helpful in finding and having a successful localization of Dieulafoy’s lesion.
Dignostic criteria for Dieulafoy’s lesion by endoscopy are:
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Micropulsatile streaming or active arterial spurting from mucosal defect less than three millimeters or through normal surrounding mucosa.
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Visual protruding vessels with or without bleeding.
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The appearance of fresh, densely adherent color with a narrow point of attachment to minute defeat or normal-appearing mucosa.
Angiography: This approach is used when the endoscopic method fails. It is useful in lesions in the colon or rectum and views obscured active bleeding and poor bowel preparation. Lesions of the anorectal region can be situated near the inferior mesenteric artery. The use of computed tomography angiography helps in locating the source of bleeding and the lesions that are missed to diagnose by endoscopic methods.
Red cell scanning: Technetium-99 m labeled red blood cell scans are used to identify the location of bleeding in cases where endoscopy fails. The threshold for detecting extravasation in the guts is only 20 percent compared with angiography.
What Is the Treatment for Dieulafoy Lesion?
Treatment of Dieulafoy’s lesion has no consensus. Treatment of the condition depends on the presentation, the site of the lesion, and the availability of expertise. The evolution of endoscopic methods has reduced the need for surgery for Dieulafoy’s lesions. The treatment approaches include the following:
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Endoscopic Treatment: Endoscopic methods are the treatment of choice, and this approach has reported more success rate and reduced the need for surgery. The procedures can be classified into three groups:
a) Thermal-electrocoagulation, argon plasma coagulation, and heat probe coagulation. b) Regional injection - local epinephrine injection and sclerotherapy.
c) Mechanical- banding and memo clip.
Each Thai technique has its disadvantages and advantages at varying success rates. EUS (endoscopic ultrasound) guided treatment of underlying vessels has given successful results. EUS helps in the detection of aberrant vessels in the submucosa. The blood flow is restricted by injecting therapy or elastic band ligation. Tattooing of the lesion is successful in minimally invasive surgical procedures.
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Angiography and Embolisation: Angiography is used to embolize active bleeding in Dieulafoy’s lesion. Lesions that failed with endoscopic methods are treated by angiography and embolization. This procedure carries a risk of ischemia of the area supplied by relevant arteries. Selective embolization is considered the treatment of choice in active bleeding cases of the gastrointestinal tract. Angiography, along with embolization, is the choice of treatment for bronchial Dieulafoy’s lesion.
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Surgical Treatment: A previously surgical approach was the only line treatment for Dieulafoy’s lesion. In this surgery, a form of gastrotomy, wide-wedge resection, or gastrectomy is done. Overtaken by endoscopic approaches, the surgical reaction is reserved for five percent of cases.
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Role of Minimally Invasive Surgery: The majority of individuals require surgery though they undergo laparotomy. The laparoscopic approach is an attractive and good option that cures while being a minimally invasive approach. The art of success depends on the accurate localization of the bleeding. Several methods have been used to ensure precise localization. Accurate intraoperative localization of lesions is a challenge for the provider.
What Are the Chances of Rebleeding in Dieulafoy Lesion After Treatment?
The risk of rebleeding from a lesion is 9 to 40 percent higher in endoscopic monotherapy compared with that of combined endoscopic therapies. Endoscopic methods of hemostasis are preferred treatment in conditions of rebleeding from Dieulafoy’s lesion. Re-bleeding is reported after embolization because of collateral circulation or incomplete embolization.
How Is the Prognosis of Dieulafoy Lesion?
The mortality rate of Dieulafoy’s lesion was much higher before endoscopy when open surgery was the only treatment. The mortality rate has decreased from 80 to 8 percent as a result of endoscopic therapies. Control of long-term bleeding is achieved in almost 85 to 90 percent of cases.
Conclusion
Management of Dieulafoy’s lesion poses a therapeutic and diagnostic challenge. This condition should be included as a differential diagnosis of obscure gastrointestinal bleeding in all age groups. Angiography is accepted as a valuable alternative to endoscopic procedures. Surgical intervention keeps failure of therapeutic endoscopic and angiographic interventions and it helps in guidance and preoperative procedure and localization of the lesion. The surgical approach always remains the preferred treatment for the lesion. Recently a laparoscopic approach has been used in managing Dieulafoy’s disease successfully.
