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The lesion in Dieulafoy's disease consists of a submucosal ectatic artery in the gastrointestinal tract. It is larger than the vessels usually in that area. It can occur in any part of the GI tract, although most frequently it is in the stomach.[1] The protuberant artery causes brisk bleeding with little or no surrounding ulceration. The aetiology of the ectatic vessel and the cause of bleeding is unknown.
Dieulafoy was a French Surgeon and was the first to describe three cases at the end of the 18th century.
Commonest sites[2]
- Proximal stomach
- Small intestine - both jejunum and ileum have been involved[3]
- Colon
- Rectum[2]
- More rare - oesophagus
Epidemiology[4]
The incidence of Dieulafoy lesion leading to GIT haemorrhage ranges from 0.5% to 14%, depending upon the study. It is commoner in men and presents around 50 years of age.
Presentation
- Bleeding - upper GIT or lower GIT
- Abdominal pain is uncommon
- Haemodynamic compromise
Investigations
Endoscopy, although repeated endoscopy may be required - especially if the lesion is not actively bleeding.[1]
Management[2]
- Resuscitation with fluids, blood etc.
- Endoscopic occlusion of the vessel, either by sclerotherapy, electrocautery or laser. Endoscopic examination and management requires careful inspection as the lesions can be easily missed.
- Rarely if the lesion can not be identified and the patient continues to bleed then surgical exploration may be necessary.
- Band ligation has also been used to treat Dieulafoy lesions with some success.[5]
Prognosis
The haemorrhage is usually difficult to manage conservatively and can be fatal. However, with meticulous examination at endoscopy the outcome is much improved.
Further reading and references
Abraham P, Mukerji SS, Desai DC, et al; Dieulafoy lesion in mid-esophagus with esophageal varices. Indian J Gastroenterol. 2004 Nov-Dec23(6):220-1.
Apiratpracha W, Ho JK, Powell JJ, et al; Acute lower gastrointestinal bleeding from a dieulafoy lesion proximal to the anorectal junction post-orthotopic liver transplant. World J Gastroenterol. 2006 Dec 1412(46):7547-8.
Fox A, Ravi K, Leeder PC, et al; Adult small bowel Dieulafoy lesion. Postgrad Med J. 2001 Dec77(914):783-4.
al-Mishlab T, Amin AM, Ellul JP; Dieulafoy's lesion: an obscure cause of GI bleeding. J R Coll Surg Edinb. 1999 Aug44(4):222-5.
Nikolaidis N, Zezos P, Giouleme O, et al; Endoscopic band ligation of Dieulafoy-like lesions in the upper gastrointestinal tract. Endoscopy. 2001 Sep33(9):754-60.