Dieulafoy's lesion
Encyclopedia
Dieulafoy's lesion is a medical condition characterized by a large tortuous arteriole
in the stomach
wall that erodes and bleeds. It can cause gastric hemorrhage 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. It is also called "caliber-persistent artery" or "aneurysm" of gastric vessels. However, unlike most other aneurysm
s these are thought to be developmental malformations rather than degenerative changes.
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%). The pathology in these extragastric locations is essentially the same as that of the more common gastric lesion.
Interestingly and 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.
and/or melena
, possibly with shock.
Reference please?
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.
Endoscopic techniques used in the treatment include epinephrine
injection followed by bipolar electrocoagulation, monopolar electrocoagulation, injection sclerotherapy, heater probe, laser photocoagulation
, hemoclipping or banding.
for Dieulafoy's was much higher before the era of endoscopy, where open surgery was the only treatment option.
Arteriole
An arteriole is a small diameter blood vessel in the microcirculation that extends and branches out from an artery and leads to capillaries.Arterioles have muscular walls and are the primary site of vascular resistance...
in the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
wall that erodes and bleeds. It can cause gastric hemorrhage but is relatively uncommon. It is thought to cause less than 5% of all gastrointestinal bleeds in adults. It was named after French
France
The French Republic , The French Republic , The French Republic , (commonly known as France , is a unitary semi-presidential republic in Western Europe with several overseas territories and islands located on other continents and in the Indian, Pacific, and Atlantic oceans. Metropolitan France...
surgeon
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
Paul Georges Dieulafoy
Paul Georges Dieulafoy
Paul Georges Dieulafoy was a French physician and surgeon. He is best known for his study of acute appendicitis and his description of Dieulafoy's lesion, a rare cause of gastric bleeding.-Life, studies, and career:...
, who described this condition in his paper "Exulceratio simplex: Leçons 1-3" in 1898. It is also called "caliber-persistent artery" or "aneurysm" of gastric vessels. However, unlike most other aneurysm
Aneurysm
An aneurysm or aneurism is a localized, blood-filled balloon-like bulge in the wall of a blood vessel. Aneurysms can commonly occur in arteries at the base of the brain and an aortic aneurysm occurs in the main artery carrying blood from the left ventricle of the heart...
s these are thought to be developmental malformations rather than degenerative changes.
Presentation
Dieulafoy's Lesions are characterized by a single large tortuous arterioleArteriole
An arteriole is a small diameter blood vessel in the microcirculation that extends and branches out from an artery and leads to capillaries.Arterioles have muscular walls and are the primary site of vascular resistance...
in the submucosa
Submucosa
In the gastrointestinal tract, the submucosa is the layer of dense irregular connective tissue or loose connective tissue that supports the mucosa, as well as joins the mucosa to the bulk of underlying smooth muscle .-Contents:Blood vessels, lymphatic vessels, and nerves will run through...
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
Duodenum
The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms anterior intestine or proximal intestine may be used instead of duodenum...
is the most common location (14%) followed by the colon (5%), surgical anastamoses (5%), the jejunum
Jejunum
The jejunum is the middle section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms middle intestine or mid-gut may be used instead of jejunum.The jejunum lies between the duodenum...
(1%) and the esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
(1%). The pathology in these extragastric locations is essentially the same as that of the more common gastric lesion.
Interestingly and in contrast to peptic ulcer disease, a history of alcohol abuse
Alcohol abuse
Alcohol abuse, as described in the DSM-IV, is a psychiatric diagnosis describing the recurring use of alcoholic beverages despite negative consequences. Alcohol abuse eventually progresses to alcoholism, a condition in which an individual becomes dependent on alcoholic beverages in order to avoid...
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 hematemesisHematemesis
Hematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract. Patients can easily confuse it with hemoptysis , although the latter is more common.-Signs:...
and/or melena
Melena
In medicine, melena or melaena refers to the black, "tarry" feces that are associated with gastrointestinal hemorrhage. The black color is caused by oxidation of the iron in hemoglobin during its passage through the ileum and colon.-Melena vs...
, possibly with shock.
| Presenting Symptoms | |
|---|---|
| Recurrent hematemesis with melena | 51% of cases |
| Hematemesis without melena | 28% of cases |
| Melena with no hematemesis | 18% of cases |
Reference please?
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
Epinephrine
Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...
injection followed by bipolar electrocoagulation, monopolar electrocoagulation, injection sclerotherapy, heater probe, laser photocoagulation
Laser photocoagulation
Laser coagulation or laser photocoagulation surgery is used to treat a number of eye diseases and has become widely used in recent decades...
, hemoclipping or banding.
Prognosis
The mortality rateMortality rate
Mortality rate is a measure of the number of deaths in a population, scaled to the size of that population, per unit time...
for Dieulafoy's was much higher before the era of endoscopy, where open surgery was the only treatment option.