Dieulafoy’s Lesion of Esophagus Managed with Injection Therapy and Cauterization

Tools

Introduction

Dieulafoy’s lesion, a dilated aberrant sub mucosal vessel which erodes the overlying epithelium in the absence of a primary ulcer, is a relatively rare but potentially fatal cause of gastrointestinal bleeding.  Most commonly, the lesion is located the lesser curvature of the stomach.  It is found less frequently in the duodenum and colon, respectively. Dieulafoy’s lesion of the esophagus is rarer still, and repeated endoscopy may be required in order to discover the lesion.

Case Report

We report the case of a 25-year-old male from Gambia, West Africa who presented to our hospital’s emergency department complaining of vomiting bright red blood for 3 days. He had been seen in emergency department of a different hospital 3 days prior and sent home, as the vomiting had resolved. He subsequently had 1 episode hematemesis so he came to our ED for further evaluation. He reported passing black stool on one occasion.  He denied abdominal pain, fever, dizziness, and shortness of breath. He denied smoking, alcohol use, or use of any drugs, except that he had taken a total of 4 Advil tablets prior to seeing melena. On examination, he was afebrile, slightly tachycardic with a pulse of108; BP was 142/85 with no orthostasis. The chest was clear. There was a grade 3 systolic murmur heard at the left lateral sternal border of the chest. The abdominal exam revealed a soft, non-tender abdomen with normoactive bowel sounds. Stool guiac was positive. Laboratory values were as follows: hemaglobin and hematocrit (H&H) 5.7g/dl/16.3%; INR 1.3; BMP revealed Na+ 140mEq, K+ 3.7mEq, Cl- 107, HCO3- 30, BUN 13, Creatinine 0.9 mg/dl, Glucose 111 mg/dl, Calcium 7.9mg/dl. Chest x-ray and plain abdominal film revealed no significant findings. EKG demonstrated sinus tachycardia at 105 bpm, but was otherwise unremarkable. GI consultation was requested, and 4 units of PRBC transfusion were recommended to keep hemoglobin above 9. Subsequently, the patient was taken for upper endoscopy.

Upper endoscopy revealed a Dieulafoy’s lesion in the mid esophagus, along with a hiatal hernia. There was active bleeding from the Dieulafoy’s lesion. which was controlled with sclerotherapy using epinephrine and cautery with BICAP. The patient was monitored in the ICU and subsequently transfused with 2 units of packed red blood cells. The blood counts stabilized, and there were no further episodes of hematemesis or melena. The patient was subsequently discharged home on a proton pump inhibitor. Discharge H&H were 7.6 g/dl and 21%.  Three days later, he returned to the ED complaining of constipation. On this admission, guiac was positive and the H&H were was 7.1g/d and 21.0%. GI consultation was again requested, and the patient was taken for repeat upper endoscopy to rule out re-bleeding from the lesion. Endoscopy demonstrated both cauterized lesions in the esophagus to be well-healed with a clean, white base. There was no evidence of recurrent bleeding. The H&H remained stable, and the patient was discharged home on iron tablets and followed in the GI clinic with no episodes of recurrent bleeding.

Dieulafoy’s Lesion & Dieulafoy’s Lesion after Injection and cauterization
Dieulafoy’s Lesion & Dieulafoy’s Lesion after Injection and cauterization

Follow up Endoscopy:

No evidence of bleeding
No evidence of bleeding

Discussion

Dieulafoy’s lesion, also known as cirsoid aneurysm and submucosal arterial malformation, was originally described by Gallard in 1884, and designated “exulceratio simplex” by the French surgeon, Georges Dieulafoy, 14 years later. It was then thought to be the initial stage of a gastric ulcer whose further development was arrested by bleeding. 4  The lesion usually occurs in the stomach, within 6 cm of the gastro duodenal junction, but has also been described in the duodenum, jejunum and colon, and very rarely in the esophagus . 2  To date, only 4 cases of Dieulafoy’s lesion of the esophagus have been reported.

Dielafoy’s lesion often presents with massive GI bleeding and hemodynamic instability. A history of gastric complaints is usually absent. Diagnosis is made by endoscopy, laparoscopy, or laparotomy. Less than 50% of the lesions are identified during the initial endoscopic examination, although repeated endoscopy will improve diagnostic yield, especially when there is active bleeding. 3  The commonly agreed endoscopic criteria for the diagnosis are: one, active arterial spurting or micro-pulsatile streaming of blood from a minute (<3 mm) mucosal defect, or through normal surrounding mucosa; two, visualization of protruding vessel, with or without active bleeding, within a minute mucosal defect or through normal surrounding mucosa; or three, fresh densely adherent clot with a narrow point of attachment to a minute mucosal defect or to normal-appearing mucosa. 3  Angiography may be useful in making the diagnosis when endoscopy fails to identify the lesion. Angiographically, Dieulafoy’s lesion appears as a non-tapering, convoluted, ecstatic caliber –persistent artery at the bleeding site, with possible extravasation of blood. 4

The treatment of Dieulafoy’s lesion consists of endoscopic hemoclip placement, band ligation, and injection therapy followed by thermal ablation, surgery or angiographic embolisation. Endoscopic therapy is reported to be successful in achieving permanent haemostasis in 85% of cases. 3  Combination therapy with injection followed by thermal probe coagulation seems to offer more secure hemostasis than monotherapy. 4  Surgery carries a mortality rate of 25% in those patients who re-bleed. Angiographic gel foam embolisation has been suggested as an alternative in patients who are not amenable to endoscopic therapy and are poor surgical candidates. 3

Conclusion

Dieulafoy’s lesion, though rare, should be a diagnostic consideration in young patients with unexplained massive GI bleeding. Repeated endoscopy may be required, which may be therapeutic as well as diagnostic.

References

  1. Usui J, Takemura H, Yuhara T, Akama T, Suzuki H, Yamane K, et al.Dieulafoy’s lesion of the esophagus as a probable complication of Takayasu’s arteritis. Journal of Rheumatology 1999; 26:454-456.

  2. Blecker D, Bansal M, Zimmerman RL, Fogt F, Lewis J, Stein R, et al. Dieulafoy’s lesion of the small bowel causing massive gastrointestinal bleeding: two case reports and literature review. American Journal of Gastroenterology 2001; 96:902-905.

  3. Ho, KM. Use of Sengstaken-Blakemore tube to stop massive upper gastrointestinal bleeding from Dieulafoy’s lesion in the lower esophagus. Anaesthesia 2004; 32:711-714.

  4. Lee Y, Walmsley RS, Leong RW, Sung JJ. Dieulafoy’s lesion. Gastrointestinal Endoscopy 2003; 58:236-243.

  5. Yoshida T, Adachi K, Tanioka Y, Sasaki T, Ono S, Hanada H, et al. Dieulafoy’s lesion of the esophagus correctly diagnosed and successfully treated by endoscopic injection of N-butyl-2-cyanoacrylate. Endoscopy 2004; 36:183-185.

  6. Ertekin C, Barbaros U, Taviloglu K, Guloglu R, Kasoglu A. Dieulafoy’s lesion of esophagus. Surgical Endoscopy 2002; 16:219.

  7. Soetikno RM, Piper J, Montes H, Ukomadu C, Carr-Locke DL. Use of endoscopic band ligation to treat a Dieulafoy’s lesion of the esophagus. Endoscopy 2000; 32:S15.

  8. Anireddy D, Timberlake G, Seibert D. Dieulafoy’s lesion of the esophagus. Gastrointestinal Endoscopy 1993; 39: 604.