Dieulafoy Lesion

Dieulafoy lesion is a large calibre (1 to 3 mm) submucosal artery that protrudes through a minute mucosal defect, causing sudden, often massive, gastrointestinal haemorrhage.

• Accounts for 1 to 2% of acute non variceal upper gastrointestinal bleeding; men more affected (2:1), median age 50 to 60.
• Located within 6 cm of the gastro oesophageal junction on the lesser curvature of the stomach in 75% (also duodenum, jejunum, colon, rectum, oesophagus).
• Mechanism: persistent calibre artery that erodes the overlying mucosa, probably with abrasion by food or pulsation; no ulcer base.
• Risk factors: cardiovascular disease, hypertension, chronic kidney disease, alcohol, NSAIDs and anticoagulants.
• High rebleeding rate without definitive therapy (up to 40% after epinephrine alone).

• Sudden painless haematemesis or melaena, frequently massive and recurrent with haemodynamic instability.
• Often without prior dyspepsia or history of ulcer disease.
• Elderly patients with comorbidities; severe anaemia, hypotension, tachycardia.

• Resuscitation, full blood count, coagulation, cross match.
• Urgent upper endoscopy (within 12 to 24 hours): pulsatile spurting vessel, protruding vessel stump with minimal surrounding mucosal defect, or adherent clot; no ulcer; may need repeated endoscopy because the lesion is intermittently bleeding and easily missed (diagnostic yield 70% at first endoscopy).
• Endoscopic ultrasound to locate the vessel; tattooing (India ink) for marking.
• CT angiography or catheter angiography for obscure ongoing bleeding with no endoscopic source; enteroscopy/capsule for small bowel lesions.
• Glasgow Blatchford score for risk.

• Resuscitation: two large bore IV lines, crystalloid, red cell transfusion (target haemoglobin 7 to 8 g/dL, higher in cardiovascular disease), correct coagulopathy (stop or reverse anticoagulants, vitamin K 10 mg, prothrombin complex), pantoprazole 80 mg IV bolus then 8 mg/h or 40 mg twice daily.
• Endoscopic haemostasis (mandatory, success 90 to 95%):
  • Mechanical therapy preferred: haemoclips (through the scope or over the scope) or band ligation, with 90% initial haemostasis and rebleeding 5 to 10%.
  • Epinephrine injection 1: 10,000 (up to 10 to 20 mL) combined with mechanical or thermal therapy; epinephrine alone has high failure.
  • Thermal: bipolar electrocoagulation, heater probe, argon plasma coagulation (secondary).
  • Haemostatic powder (Hemospray) for rescue.
• Repeat endoscopy for rebleeding. Consider endoscopic tattoo of the lesion.
• Angiographic embolisation (gelfoam, coils) if endoscopy fails (success 80 to 90%).
• Surgery: wedge resection or gastric resection (with oversewing) for refractory cases, guided by tattoo or intraoperative endoscopy.
• After control, PPI therapy, stop NSAIDs, review antithrombotic therapy.
• Prognosis is good with modern endoscopic therapy; mortality under 5%.