Dieulafoy's lesion

Dieulafoy's lesion

Blood supply of stomach
Classification and external resources
Specialty	gastroenterology
ICD-10	K25
ICD-9-CM	537.84
DiseasesDB	33135

Dieulafoy's lesion (exulceratio simplex Dieulafoy) is a medical condition characterized by a large tortuous arteriole most commonly in the stomach wall (submucosal) that erodes and bleeds. It can present in any part of the gastrointestinal tract.^[1] It can cause gastric hemorrhage^[2] but is relatively uncommon. It is thought to cause less than 5% of all gastrointestinal bleeds in adults. It was named after French surgeon Paul Georges Dieulafoy, who described this condition in his paper "Exulceratio simplex: Leçons 1-3" in 1898.^[3]^[4] It is also called "caliber-persistent artery" or "aneurysm" of gastric vessels. However, unlike most other aneurysms these are thought to be developmental malformations rather than degenerative changes.

Presentation

Dieulafoy's Lesions are characterized by a single large tortuous small artery^[5] in the submucosa which does not undergo normal branching or a branch with caliber of 1–5 mm (more than 10 times the normal diameter of mucosal capillaries). The lesion bleeds into the gastrointestinal tract through a minute defect in the mucosa which is not a primary ulcer of the mucosa but an erosion likely caused in the submucosal surface by protrusion of the pulsatile arteriole.

Approximately 75% of Dieulafoy's lesions occur in the upper part of the stomach within 6 cm of the gastroesophageal junction, most commonly in the lesser curvature. Extragastric lesions have historically been thought to be uncommon but have been identified more frequently in recent years, likely due to increased awareness of the condition. The duodenum is the most common location (14%) followed by the colon (5%), surgical anastamoses (5%), the jejunum (1%) and the esophagus (1%).^[6] The pathology in these extragastric locations is essentially the same as that of the more common gastric lesion.

In contrast to peptic ulcer disease, a history of alcohol abuse or NSAID use is usually absent in DL.

Dieulafoy's lesions occur twice as often in men as women and patients typically have multiple comorbidities, including hypertension, cardiovascular disease, chronic kidney disease, and diabetes.

Symptoms

The symptoms due to bleeding are hematemesis and/or melena.^[1]

Presenting Symptoms
Recurrent hematemesis with melena	51% of cases
Hematemesis without melena	28% of cases
Melena with no hematemesis	18% of cases

A Dieulafoy's lesion is difficult to diagnose, because of the intermittent pattern of bleeding. Endoscopically it is not easy to recognize and therefore sometimes multiple views have to be performed over a longer period. Today angiography is a good additional diagnostic, but then it can only be seen during a bleeding at that exact time.

Treatment

It is diagnosed and treated endoscopically; however, endoscopic ultrasound or angiography can be of benefit.

Endoscopic techniques used in the treatment include epinephrine injection followed by bipolar or monopolar electrocoagulation, injection sclerotherapy, heater probe, laser photocoagulation, hemoclipping or banding. Alternatively, in patients with refractory bleeding Interventional Radiology may be consulted for an angiogram with subselective embolization.^[7]

Prognosis

The mortality rate for Dieulafoy's was much higher before the era of endoscopy, where open surgery was the only treatment option.

References

1 2 al-Mishlab T, Amin AM, Ellul JP (August 1999). "Dieulafoy's lesion: an obscure cause of GI bleeding.". Journal of the Royal College of Surgeons of Edinburgh. 44 (3): 222–5. PMID 10453143.
↑ Akhras J, Patel P, Tobi M (March 2007). "Dieulafoy's lesion-like bleeding: an underrecognized cause of upper gastrointestinal hemorrhage in patients with advanced liver disease". Dig. Dis. Sci. 52 (3): 722–6. doi:10.1007/s10620-006-9468-7. PMID 17237996.
↑ synd/3117 at Who Named It?
↑ G. Dieulafoy. Exulceratio simplex: Leçons 1-3. In: G. Dieulafoy, editor: Clinique medicale de l'Hotel Dieu de Paris. Paris, Masson et Cie: 1898:1-38.
↑ Eidus, LB.; Rasuli, P.; Manion, D.; Heringer, R. (Nov 1990). "Caliber-persistent artery of the stomach (Dieulafoy's vascular malformation).". Gastroenterology. 99 (5): 1507–10. PMID 2210260.
↑ Lee Y, Walmsley R, Leong R, Sung J (2003). "Dieulafoy's Lesion". Gastrointestinal Endoscopy. 58 (2): 236–243. doi:10.1067/mge.2003.328. PMID 12872092.
↑ Navuluri, Rakesh; Kang, Lisa; Patel, Jay; Van Ha, Thuong (2012-09-01). "Acute Lower Gastrointestinal Bleeding". Seminars in Interventional Radiology. 29 (3): 178–186. doi:10.1055/s-0032-1326926. ISSN 0739-9529. PMC 3577586. PMID 23997409.

Diseases of the digestive system (primarily K20–K93, 530–579)

Upper GI tract

Esophagus	Esophagitis Candidal Eosinophilic Herpetiform Rupture Boerhaave syndrome Mallory-Weiss syndrome UES Zenker's diverticulum LES Barrett's esophagus Esophageal motility disorder Nutcracker esophagus Achalasia Diffuse esophageal spasm Gastroesophageal reflux disease (GERD) Laryngopharyngeal reflux (LPR) Esophageal stricture Megaesophagus

Stomach	Gastritis Atrophic Ménétrier's disease Gastroenteritis Peptic (gastric) ulcer Cushing ulcer Dieulafoy's lesion Dyspepsia Pyloric stenosis Achlorhydria Gastroparesis Gastroptosis Portal hypertensive gastropathy Gastric antral vascular ectasia Gastric dumping syndrome Gastric volvulus

Lower GI tract:
Intestinal/
Enteropathy

Small intestine (Duodenum/Jejunum/Ileum)	Enteritis Duodenitis Jejunitis Ileitis Peptic (duodenal) ulcer Curling's ulcer Malabsorption: Coeliac Tropical sprue Blind loop syndrome Small bowel bacterial overgrowth syndrome Whipple's Short bowel syndrome Steatorrhea Milroy disease Bile acid malabsorption

Large intestine (Appendix/Colon)	Appendicitis Colitis Pseudomembranous Ulcerative Ischemic Microscopic Collagenous Lymphocytic Functional colonic disease IBS Intestinal pseudoobstruction / Ogilvie syndrome Megacolon / Toxic megacolon Diverticulitis/Diverticulosis

Large and/or small	Enterocolitis Necrotizing Gastroenterocolitis IBD Crohn's disease Vascular: Abdominal angina Mesenteric ischemia Angiodysplasia Bowel obstruction: Ileus Intussusception Volvulus Fecal impaction Constipation Diarrhea Infectious Intestinal adhesions

Rectum	Proctitis Radiation proctitis Proctalgia fugax Rectal prolapse Anismus

Anal canal	Anal fissure/Anal fistula Anal abscess Anal dysplasia Pruritus ani

GI bleeding/BIS

Accessory

Liver	Hepatitis Viral hepatitis Autoimmune hepatitis Alcoholic hepatitis Cirrhosis PBC Fatty liver NASH Vascular Budd-Chiari syndrome Hepatic veno-occlusive disease Portal hypertension Nutmeg liver Alcoholic liver disease Liver failure Hepatic encephalopathy Acute liver failure Liver abscess Pyogenic Amoebic Hepatorenal syndrome Peliosis hepatis Metabolic disorders Wilson's disease Hemochromatosis

Gallbladder	Cholecystitis Gallstones/Cholecystolithiasis Cholesterolosis Rokitansky-Aschoff sinuses Postcholecystectomy syndrome Porcelain gallbladder

Bile duct/ Other biliary tree	Cholangitis Primary sclerosing cholangitis Secondary sclerosing cholangitis Ascending Cholestasis/Mirizzi's syndrome Biliary fistula Haemobilia Gallstones/Cholelithiasis Common bile duct Choledocholithiasis Biliary dyskinesia Sphincter of Oddi dysfunction

Pancreatic	Pancreatitis Acute Chronic Hereditary Pancreatic abscess Pancreatic pseudocyst Exocrine pancreatic insufficiency Pancreatic fistula

Abdominopelvic

Hernia	Diaphragmatic Congenital Hiatus Inguinal Indirect Direct Umbilical Femoral Obturator Spigelian Lumbar Petit's Grynfeltt-Lesshaft Undefined location Incisional Internal hernia Richter's

Peritoneal	Peritonitis Spontaneous bacterial peritonitis Hemoperitoneum Pneumoperitoneum

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