The efficacy of sclerotherapy as the initial treatment in patients with bleeding from Dieulafoy's lesion of the upper gastrointestinal tract.

BACKGROUND: Dieulafoy's lesion (DL) is a rare and important cause of acute nonvariceal upper gastrointestinal bleeding (ANVUGIB), however, there is a lack of clear guidelines focus on the endoscopic hemostasis treatment for DL. Sclerotherapy, as the ANVUGIB guideline recommended endoscopic hemostasis method, is widely used in clinical practice. The aim of this study is to investigate the efficacy of sclerotherapy as the initial treatment for Dieulafoy's lesion of the upper gastrointestinal tract (UDL). METHODS: Patients with UDL who underwent the ANVUGIB standard endoscopic hemostasis between April 2007 and January 2023 were enrolled. The endoscopic therapy method was left to the discretion of the endoscopist. RESULTS: In total, 219 patients were finally obtained, with 74 (33.8%) receiving sclerotherapy and 145 (66.2%) receiving other standard endoscopic therapy. The rebleeding within 30 days was significantly lower in the sclerotherapy group compared to the other standard group (5.8% vs. 16.8%, p = 0.047). There were no significant differences between the two groups in terms of successful hemostasis rate (93.2% vs. 94.5%, p = 0.713), median number of red blood cell transfusions (3.5 vs. 4.0 units, p = 0.257), median hospital stay (8.0 vs. 8.0 days, p = 0.103), transferred to ICU rate (8.1% vs. 6.2%, p = 0.598), the need for embolization or surgery rate (12.2% vs. 9.7%, p = 0.567) and 30-day mortality (0 vs. 2.1%, p = 0.553). In addition, we found no difference in efficacy between sclerotherapy alone and combination (3.1% vs. 8.1%, p = 0.714). Further analysis revealed that thermocoagulation for hemostasis was associated with a higher rate of rebleeding (28.6% vs. 3.1%, p = 0.042) and longer hospital stay (11.5 vs. 7.5 days, p = 0.005) compared to sclerotherapy alone. CONCLUSION: Sclerotherapy represents an effective endoscopic therapy for both alone and combined use in patients with upper gastrointestinal Dieulafoy's lesion. Therefore, sclerotherapy could be considered as initial treatment in patients with bleeding of UDL.

Fatal exulceratio simplex (dieulafoy lesion) - a case report and review.

A 64-year-old man involved in a low-speed vehicle crash was found at autopsy to have altered blood extending from his stomach to his rectum. Within the stomach a small arterial vessel opened onto the mucosa of the posterior wall of the antrum adjacent to the pylorus with no adjacent mucosal ulceration or malignancy. Histologic sections showed the typical appearances of a Dieulafoy lesion with a tortuous small arteriole within the submucosa extending to the gastric lumen with an overlying cap of recently formed clot. There were no injuries attributable to the vehicle collision. Death was due to a bleeding Dieulafoy lesion of the stomach with a background of cardiomegaly. Dieulafoy lesion of the stomach is a rare disorder accounting for only 1-2% of cases of acute gastrointestinal hemorrhage. Although its pathogenesis is poorly understood it is capable of producing life-threatening bleeding, as in the present case. The small size of the lesion may make it difficult to identify at the time of autopsy.

Clinical characteristics of Dieulafoy's lesion in the small bowel diagnosed and treated by double-balloon endoscopy.

BACKGROUND: Obscure gastrointestinal bleeding refers to bleeding for which the source cannot be ascertained even through balloon-assisted endoscopy. In certain instances, Dieulafoy's lesion in the small bowel is presumed to be the underlying cause. AIM: This retrospective study aimed to elucidate the clinical characteristics of Dieulafoy's lesion in the small bowel as diagnosed via double-balloon endoscopy while also exploring the feasibility of predicting bleeding from Dieulafoy's lesion prior to endoscopy in cases of obscure gastrointestinal bleeding. METHODS: A comprehensive analysis of our database was conducted, identifying 38 patients who received a diagnosis of Dieulafoy's lesion and subsequently underwent treatment via double-balloon endoscopy. The clinical background, diagnosis, and treatment details of patients with Dieulafoy's lesion were carefully examined. RESULTS: The median age of the 38 patients was 72 years, and 50% of the patients were male. A total of 26 (68%) patients exhibited a high comorbidity index. The upper jejunum and lower ileum were the most frequently reported locations for the occurrence of Dieulafoy's lesion in the small bowel. The detected Dieulafoy's lesions exhibited active bleeding (n = 33) and an exposed vessel with plaque on the surface (n = 5). Rebleeding after endoscopic treatment occurred in 8 patients (21%, median period: 7 days, range: 1-366 days). We conducted an analysis to determine the definitive nature of the initial double-balloon endoscopy diagnosis. Multivariate analysis revealed that hematochezia of ≥ 2 episodes constituted the independent factor associated with ≥ 2 double-balloon endoscopy diagnoses. Additionally, we explored factors associated with rebleeding following endoscopic treatment. Although the number of hemoclips utilized displayed a likely association, multivariate analysis did not identify any independent factor associated with rebleeding. CONCLUSION: If a patient encounters multiple instances of hematochezia, promptly scheduling balloon-assisted endoscopy, equipped with optional instruments without delay is advised, after standard endoscopic evaluation with esophagogastroduodenoscopy and colonoscopy is unrevealing.

Clinical outcomes of Dieulafoy's lesion compared with peptic ulcer in upper gastrointestinal bleeding.

BACKGROUND AND AIM: Although Dieulafoy's lesion (DL) is an important cause of nonvariceal upper gastrointestinal (GI) bleeding, few studies have investigated the clinico-epidemiological outcomes due to its rarity. Here, we investigated clinical features of upper GI bleeding caused by peptic ulcer (PU) or DL and compared endoscopic treatment outcomes. METHODS: Patients with upper GI bleeding resulting from PU or DL who visited emergency room between January 2013 and December 2017 were eligible. Clinical features and treatment outcomes were retrospectively investigated. RESULTS: Overall, 728 patients with upper GI bleeding due to PU (n = 669) and DL (n = 59) were enrolled. The median age was 64 years (interquartile range [IQR], 56-75 years), and 74.3% were male. Endoscopic intervention was performed in 53.7% (n = 359) and 98.3% (n = 58) of the PU and DL groups, respectively (P < 0.0001). Patients were matched by sex, age, body mass index, comorbidity, and past medical history, and 190 PU and 52 DL were finally selected. The rebleeding rates within 7 (7.37% vs 17.31%, P = 0.037) and 30 (7.37% vs 26.92%, P < 0.001) days after initial endoscopy were significantly lower in the PU than in the DL group after propensity score matching. During the median follow-up period of 52 months (IQR, 34-70 months), there was no difference in overall survival rate (67.9% vs 82.7%, P = 0.518). CONCLUSIONS: Although DL is a rare cause of upper GI bleeding, it requires endoscopic hemostasis more frequently and has a higher rate of rebleeding than PU even after therapeutic endoscopy. Endoscopists should pay attention and perform active endoscopic hemostasis for DL bleeding.

A Case Report of Profuse Bleeding in the Lower Gastrointestinal Tract due to Dieulafoy Lesion in the Rectum.

Dieulafoy lesion is a rare condition that usually occurs in cases of gastric bleeding in the upper gastrointestinal tract. However, this condition can also occur in the lower gastrointestinal tract but less frequently. The lesion is an arteriolar malformation that extends to the submucosa, causing erosion and bleeding. Meanwhile, this is a case of a 67-year-old woman presenting with a bright red bloody stool prior to admission, as well as a history of constipation which was relieved by digital stool evacuation two weeks earlier. The medical history of the patient reveals episodes of  repeated ischaemic stroke for over seven years and three months, which has led to other conditions such as right-sided paralysis, transcortical motor aphasia, and neurogenic dysphagia. The patient was routinely on antithrombotic medications, which was stopped during hospitalisation where repeated packed cell transfusion was done in order to avoid hematochezia. The patient needed the support of her caregiver most of the time since she was bedridden. Furthermore, the haemostasis and platelet function of the patient were normal. On colonoscopy, there was the discovery of a small lesion of about 3mm in her rectum, protruding into the lumen and pulsated, which was discovered to be Dieulafoy's lesion. Subsequently, this lesion was closed using rubber band ligation, and after a month, there was no recurrence of the lower gastrointestinal bleeding.

Case report: fatal bleeding from a duodenal ulcer-Dieulafoy's lesion?

A 46-year-old man was admitted to the hospital by ambulance due to syncope. A standard blood screening showed a normal Hb value. The man had known hemorrhoids and a single fresh rectal bleeding earlier at home. On the following morning, the patient suddenly required resuscitation within a few minutes and subsequently died. Autopsy revealed a fatal hemorrhage with blood loss in the stomach and small and large intestines and a mucosal defect of the duodenum. After autopsy, the question arose whether the cause of death might have been a rare Dieulafoy's lesion-aim of this case report was to clarify the diagnosis.

Meckel's Diverticulum with Dieulafoy's Lesion: A Cause of Severe Hematochezia.

BACKGROUND: Meckel's diverticulum (MD) is a remnant of the omphalomesenteric duct. Although the majority of MD are asymptomatic, it can present with severe hematochezia. Hematochezia is generally considered to result from a peptic ulcer caused by ectopic gastric mucosa in MD. However, this hypothesis has not been proved. METHODS: 10 cases of surgically resected MD initially presenting with severe hematochezia were histologically examined. RESULTS: Ectopic gastric mucosa was present in 9 cases, two of which also contained ectopic pancreas. No ectopic tissue was found in one case, which shows that bleeding can occur in MD without ectopic gastric mucosa. In addition, a rupture of aberrant submucosal arterioles through the overlying mucosa, a vascular abnormality called Dieulafoy's lesion, was detected in all the 10 cases. CONCLUSION: This study suggests that the actual cause of massive bleeding in MD is not a peptic ulcer, but Dieulafoy's lesion.

Randomized Controlled Trial of Over-the-Scope Clip as Initial Treatment of Severe Nonvariceal Upper Gastrointestinal Bleeding.

BACKGROUND AND AIMS: No prior randomized controlled trial (RCT) has reported patient outcomes of large over-the-scope clip (OTSC) compared to standard hemostasis as initial endoscopic treatment of severe NVUGIB. This was our study aim. METHODS: Patients with bleeding ulcers or Dieulafoy's lesions and major stigmata of hemorrhage - SRH (active spurting bleeding, visible vessel, or clot) - or lesser SRH (oozing bleeding or flat spots - with arterial blood flow by Doppler probe) were randomized to OTSC or standard endoscopic hemostasis (with hemoclips or multipolar electrocoagulation - MPEC). Patients and their healthcare providers were blinded to treatments and made all post-randomization management decisions. Ulcer patients received high dose intravenous infusions of proton pump inhibitors (PPI) for 3 days, then 27 days of oral PPI. 30 day outcomes were prospectively recorded; data management was with SAS; and data analysis was by a statistician. RESULTS: 53 patients (25 OTSC, 28 Standard) were randomized, with similar baseline risk factors. However, there were significant differences in OTSC vs. Standard groups in rates of rebleeding (4% vs. 28.6%; p = .017; relative risk 0.10, 95% confidence intervals 0.01, 0.91; number needed to treat 4); severe complications (0 % vs. 14.3%); and post-randomization units of red cell transfusions (0.04 vs. 0.68). All rebleeds occurred in patients with major SRH and none with lesser SRH. CONCLUSION: 1. OTSC significantly reduced rates of rebleeding, severe complications, and post-randomization red cell transfusions. 2. Patients with major stigmata benefited significantly from hemostasis with OTSC, but those with lesser stigmata did not. (ClinicalTrials.gov, Number: NCT03065465).

Outcomes in Severe Upper GI Hemorrhage from Dieulafoy's Lesion with Monitoring of Arterial Blood Flow.

BACKGROUND: Dieulafoy's lesion (DL) is a rare but increasingly recognized cause of severe upper GI hemorrhage (SUGIH). There is little consensus regarding the endoscopic approach to management of bleeding from DL. AIMS: Our purposes were to compare 30-day outcomes of patients with SUGIH from DL with Doppler endoscopic probe (DEP) monitoring of blood flow and guided treatment versus standard visually guided hemostasis (VG). METHODS: Eighty-two consecutive DL patients with SUGIH were identified in a large CURE Hemostasis database from previous prospective cohort studies and two recent RCTs at two university-based medical centers. 30-day outcomes including rebleeding, surgery, angiography, death, and severe medical complications were compared between the two treatment groups. RESULTS: 40.2% of DL bleeds occurred in inpatients. 43.9% of patients had cardiovascular disease, and 48.7% were taking medications associated with bleeding. For the entire cohort, 41.3% (26/63) of patients treated with VG had a composite 30-day outcome as compared to 10.5% (2/19) of patients treated with DEP (p = 0.017). Rebleeding occurred within 30 days in 33.3% and 10.5% of those treated with VG and DEP, respectively (p = 0.051). After propensity score matching, the adjusted 30-day composite outcome occurred in 39.0% in the VG group compared to 2.6% in the DEP group (p < 0.001). Adjusted 30-day rebleeding occurred in 25.3% in the VG group versus 2.6% in the DEP group (p < 0.001). DISCUSSION: DL patients with SUGIH were frequently inpatients and had severe cardiovascular comorbidities and recurrent bleeding. Lesion arterial blood flow monitoring and obliteration are an effective way to treat bleeding from DL which reduces negative 30-day clinical outcomes.

Ileal Dieulafoy lesion arose 15 years after partial small bowel resection for meconium obstruction of the neonate: a case report.

BACKGROUND: Anastomotic or perianastomotic ulcers present with symptoms such as chronic anaemia and occult bleeding as long-term complications of bowel resection performed in infancy. CASE PRESENTATION: Herein, we describe a 15-year-old girl with a history of surgery for meconium obstruction without mucoviscidosis in infancy who was hospitalized with chief complaints of presyncope and convulsions. Seven hours after admission, she developed melena and went into shock. An emergency laparotomy was performed, and a Dieulafoy lesion was detected near the site of ileal anastomosis from the surgery that had been performed during infancy. CONCLUSIONS: Although overt massive lower gastrointestinal bleeding necessitating emergency care is rare in the long term after infant bowel resection, Dieulafoy lesions can cause serious bleeding, requiring rapid life-saving haemostatic procedures.

Massive paediatric pulmonary haemorrhage in Dieulafoy's disease: Roles of CT angiography, embolisation and bronchoscopy.

Acute, major pulmonary haemorrhage in children, is rare, may be life-threatening and at times presents atypically. Dieulafoy's disease of the bronchus presenting with recurrent or massive hemoptysis was first described in adults. Prior to reviewing the literature, we report an illustrative case of bronchial Dieulafoy's disease (BDD) in a child presenting unusually with massive apparent hematemesis. The source of bleeding is a bronchial artery that fails to taper as it terminates within the bronchial submucosa. A high index of suspicion is required to identify such lesions via radiological imaging and the role of bronchial artery embolisation is highlighted with video images of angiography included.

Dieulafoys jejunal lesion as a source of lifethreating bleeding.

Dieulafoy`s lesion is a rare condition characterized by bleeding into gastrointestinal tract from minimaly eroded submucous artery. Mostly is localized in stomach in elderly polymorbid men, but can occure in entire gastrointestinal tract, in both sexes, in every age. It should be thought off as one of possible causes of obscure bleeding. It is often massive, requiring fast diagnostics, treatment and multidisciplinary approach. The case report discusses patient with recurrent hemodynamicaly significant bleeding into jejunum. It pointed to combined diagnostic approach using both endoscopy and angiography. After failing endoscopically and angiografically due to hemodynamic instability, surgical intervention took place. Precise Dieulafoy`s lesion diagnosis has been determined eventually on histologic section. Diagnostic and therapeutic approach should be individual taking patient´s condition and capabilities of department into consideration. Surgical intervention remains golden standard when hemodynamic instability occures or when endoscopy and angiography fail.

Bronchial Dieulafoy's disease: a retrospective analysis of 73 cases.

BACKGROUND: Bronchial Dieulafoy's disease (BDD) is a rare disease that is known to be a cause of hemorrhage. The characteristics of this disease are still unknown. The present study describes the disorder based on a review of the world's literature, emphasizing the diagnostic and therapeutic views. METHODS: A comprehensive research of BDD of the PubMed, Google Scholar, and Web of Science databases was performed. The following data were collected: patient characteristics; chest imaging, bronchoscopy, vascular angiography, and histopathologic examination findings; and treatment rendered. RESULTS: 73 cases of BDD have been reported from 1995 to 2019. Most of the cases occurred in Asia (52.1%), followed by Europe (31.5%). Chest imaging findings were non-specific. The main bronchoscopy finding was a nodular or protruding lesion (60.9%). 19 patients underwent bronchoscopic biopsies, 17 had bleeding, and 6 died. Four patients were successfully shown to have vascular malformations under mucosal protrusion by endobronchial ultrasound scan (EBUS). Vascular angiography mainly showed tortuous, dilated bronchial arteries. Vascular angiography mainly showed tortuous, dilated bronchial arteries. The arterial supply was mainly provided by bronchial arteries (48 cases) and the pulmonary circulation (4 cases). The lesions were mainly located in the right bronchus (53 cases). Selective bronchial artery embolization (BAE) was attempted in 38 patients and 20 patients underwent lobectomies. Emergency resection was performed in 15 patients, all of whom survived and had no recurrent hemoptysis. CONCLUSIONS: Massive hemoptysis was the common manifestation of BDD. Vascular angiography and EBUS is a very useful examination before biopsy. BAE may be used in stable patients, or patients who cannot tolerate surgery, while surgical resection should be considered in patients who are unstable, patients with uncontrolled hemoptysis, or following BAE failure.

Dieulafoy lesions and PHACE syndrome.

Dieulafoy's lesion (DL) is a small gastrointestinal (GI) mucosal erosion due to an abnormally large caliber and persistent submucosal arteriole. Typically occurring in adults, they are an extremely rare cause of GI bleeding in pediatrics. We report a case of multiple jejunal DLs in a 9-year-old girl with posterior fossa brain malformations, hemangiomas, arterial lesions, cardiac abnormalities, eye abnormalities (PHACE) syndrome, and the first described use of rapamycin in the treatment of pediatric DLs.

[The computed tomography angiography features of Dieulafoy disease of the bronchus].

Objectives: To summarize the computed tomography angiography(CTA) features of Dieulafoy disease of the bronchus. Methods: The clinical, imaging and pathological data of Dieulafoy disease of the bronchus diagnosed in our hospital from July 4, 2010 to June 20, 2016 were retrospectively analyzed, and the CTA imaging features of the abnormal bronchial arteries were summarized. Results: There were 6 cases of bronchial Dieulafoy disease, 5 males and 1 female, with an average age of (55±15) years. Three cases had smoking history, and 2 cases had underlying diseases such as tuberculosis and acute myeloid leukemia. The common manifestations were hemoptysis, fever and pneumonia. Three patients got CTA examination, and bronchial arteries of Dieulafoy disease of the bronchus were circuitous and dilated, with the vascular diameter lager than 2 mm, no gradual narrowing but sudden truncation. Some circuitous vessels went into bronchial lumen as nodules. The bronchoscopy biopsy of 2 cases of bronchial nodules led to severe hemorrhage, with one death and one survival by successful management. Conclusions: Bronchial arteries of Dieulafoy disease of the bronchus were circuitous and dilated, and some circuitous vessels went into bronchial lumen as nodules, this demonstration can be used to diagnose Dieulafoy disease of the bronchus. For patients with hemoptysis, bronchial biopsy should only be performed after CTA examination if this disease is suspected.

Life-threatening bleeding from gastric dieulafoy's lesion in a pregnant woman with hellp syndrome: a case report and literature review.

BACKGROUND: Dieulafoy's lesion (DL) is one of the rare causes of upper gastrointestional bleeding. This disease is characterized by small sub-mucosal arteriole that eroded the stomach mucosa and cause severe upper GI bleeding without obvious ulceration. The most common location is fundus area of stomach and usually affects patients over 50 years of age with multiple comorbidities. CASE PRESENTATION: We report a case of life-threatening bleeding from DL during late pregnancy 31 weeks. Hemoclips were used twice through upper endoscopy with successful hemostasis. Unfortunately, she developed HELLP syndrome diagnosed 5 days after the GI bleeding was stopped. Her pregnancy had to be terminated with delivery of a premature infant. She recovered from her illness and discharged from hospital uneventfully. There is no current report in literature of DL in pregnant woman subsequently suffered HELLP syndrome. CONCLUSION: Endoscopic hemoclip application is an effective technique in the treatment of upper GI bleeding from DL. For this patient, laparoscopic surgery or combination therapy before pregnancy may have been a suitable treatment on preventing rebleeding.

Emergency double-balloon enteroscopy combined with real-time viewing of capsule endoscopy: a feasible combined approach in acute overt-obscure gastrointestinal bleeding?

BACKGROUND AND AIM: There are few data concerning emergency double-balloon enteroscopy (DBE) and its usefulness in the management of severe acute obscure gastrointestinal bleeding (OGIB). The aim of this retrospective study was to evaluate emergency DBE and capsule endoscopy (CE) in patients with overt OGIB, analyzing the feasibility of this combined approach. METHODS: Emergency DBE in patients with overt OGIB was defined as performance within 24 h of symptom onset. We reported 27 patients (16 men, mean age: 64.6 ± 17.9 years) with overt severe bleeding who underwent 29 emergency DBE (22 anterograde, 7 retrograde). Of 27 patients, 16 (59.3%) underwent CE with real time (RT) viewing. RESULTS: Patients were diagnosed with the following: Dieulafoy's lesion (DL; n = 11, 40.7%), angioectasia (n = 7, 25.9%), tumors (n = 4, 14.8%), diverticulum (n = 3, 11.1%), ulcers (n = 2, 7.4%). We diagnosed 23 lesions amenable to endoscopic hemostasis and successfully treated 21 of them (77.8%). DL detection rate was statistically higher in the emergency DBE group than in OGIB patients with DBE done 24 h after symptom onset (40.7% vs 0.9%, respectively, P < 0.001). Combined approach with RT viewing by CE correctly modified DBE management in four patients (25%). CONCLUSIONS: Emergency DBE is feasible, safe and effective in acute OGIB and may avoid major surgery, diagnosing and successfully treating most patients. Combined approach with RT viewing by CE is especially useful to identify recurrent bleeding vascular lesions such as DL that may be easily misdiagnosed by non-emergency DBE.

Massive lower gastrointestinal bleeding from a jejunal Dieulafoy lesion.

Dieulafoy lesion should be considered in massive gastrointestinal bleeding that may be difficult to localize. If the endoscopic and angiographic approaches fail, surgery must be considered according to the patient's clinical condition within an appropriate time. Although mostly seen in the stomach of old male patients with co-morbidities, here we presented a Dieulafoy lesion in the jejunum of a 21-year-old female patient without any significant comorbidity. After endoscopic and angiographic attempts, surgical resection with the help of intraoperative endoscopy was performed. It was shown that perioperative endoscopy may reveal the localization of jejunal bleedings and may guide the definitive treatment.