What is a Dieulafoy’s Lesion?
Dieulafoy’s lesion is a disease where the patient develops large twisted arteriole usually in the wall of the stomach (1, 2, 4). There is erosion and bleeding from this twisted arteriole and this lesion can develop in any part of the gastrointestinal tract and can also sometimes lead to gastric hemorrhage. About less than 4% of all GI hemorrhage in adults occur as a result of Dieulafoy’s lesion (3).
Who Discovered Dieulafoy’s Lesion?
This condition was named after the French Doctor Paul G. Dieulafoy, who characterized this disease (5). Dieulafoy’s lesion is also known as “aneurysm” of the gastric vessels or “caliber-persistent artery.” However, Dieulafoy’s lesion is considered as developmental malformations, instead of degenerative changes as seen in regular aneurysms.
What is the Cause of Dieulafoy’s Lesion?
An abnormally large and twisted arteriole present under the gastrointestinal mucosa causes Dieulafoy’s lesion and there is bleeding from the lesion without any ulcer or other mucosal abnormality. The size of these twisted blood vessels can range from 1 to 3 mm. It is thought that the pulsation from the enlarged arteriole causes thinning of the mucosa (erosion) in that area resulting in exposure of the large arteriole and subsequent bleeding.
As opposed to peptic ulcer disease, there is no history of NSAIDs use or alcohol abuse in patient suffering from Dieulafoy’s lesion. This condition can affect any area of the gastrointestinal tract and has also been seen in the gallbladder.
Pathophysiology of Dieulafoy’s Lesions
A single large tortuous artery is the primary characteristic feature of Dieulafoy’s lesion. This lesion is present in sub-mucosa and only has a branch ranging in width of 1 to 5 mm. Dieulafoy’s lesion bleeds within the GI tract via a small defect in the mucosa that is caused by erosion due to protrusion of the pulsatile arteriole in the sub-mucosal surface.
The most common location for Dieulafoy’s lesion is the duodenum followed by the colon, after which surgical Anastomosis; then the jejunum followed by less commonly in the esophagus (about 1%).
More than half of the Dieulafoy’s lesions develop within 6 cm of the gastroesophageal junction that is in the upper part of the stomach and less commonly in the lesser curvature. Dieulafoy’s lesion outside of the stomach is uncommon; however, have been reported more frequently recently. This can be due to the increased awareness of this disease. The pathological features of the Dieulafoy’s lesions found outside the stomach is basically the same that is seen in those present in the GI tract.
What are the Signs & Symptoms of Dieulafoy’s Lesion?
Dieulafoy’s lesion is commonly asymptomatic; symptoms when present consist of painless bleeding with hematemesis and/or melena (black stools). Less commonly rectal bleeding can occur due to Dieulafoy’s lesions or rarely there can be iron deficiency anemia seen in the patient. Patient having Dieulafoy’s lesion usually does not present with any gastrointestinal symptoms (nausea, abdominal pain etc.) before the bleeding.
Some of the symptoms seen in Dieulafoy’s lesion include:
- Hematemesis without melena is seen in about 28% of patients.
- Recurrent hematemesis with melena is seen in about 51% of patients;
- Melena with no hematemesis is seen in about 18% of the patients suffering with Dieulafoy’s lesion.
Some rare symptoms occurring as a result of Dieulafoy’s lesions present in gallbladder consists of upper abdominal pain, commonly in the right upper quadrant or epigastric region. Even though Dieulafoy’s lesions in gallbladder often occur with anemia, they usually do not cause excessive bleeding (hematemesis, hematochezia, melena, etc).
Epidemiology of Dieulafoy’s Lesion
About more than 1% of gastrointestinal bleeding is caused by Dieulafoy’s lesions. Dieulafoy’s lesion is also commonly seen to develop in patients over the age of 50 years and having multiple co-morbidities, such as hypertension, chronic kidney disease, cardiovascular disease and diabetes (6). Men are twice at risk for developing these lesions than women (5).
How is the Diagnosis of Dieulafoy’s Lesion Made?
It is difficult to diagnose Dieulafoy’s lesion, because of the intermittent nature of the bleeding (5). During an endoscopic evaluation and most commonly the upper endoscopy, the diagnosis of Dieulafoy’s lesion is made. Dieulafoy’s lesion present in the colon or the terminal ileum can be diagnosed during colonoscopy. It is difficult to identify Dieulafoy’s lesions and multiple evaluations with endoscopy are needed for the right diagnosis. Angiography can also help with diagnosis of Dieulafoy’s lesion; however, this only helps in identifying active bleeding occurring during the time of the procedure.
After Dieulafoy’s lesion has been noted, the mucosa adjacent to the Dieulafoy’s lesion will be injected with ink; this will help in identifying the site of the Dieulafoy’s lesion if there is any recurrent bleeding in the future.
What is the Treatment for Dieulafoy’s Lesion?
Dieulafoy’s lesion is diagnosed as well as treated via endoscopy. Other than this, angiography or endoscopic ultrasound can also be beneficial with the diagnosis of the Dieulafoy’s lesion.
The endoscopic techniques for treating Dieulafoy’s lesion consist of: epinephrine injection followed by monopolar or bipolar electrocoagulation; injection sclerotherapy; heater probe; laser photocoagulation; banding or hemoclipping (7).
If the patient has stubborn or persistent bleeding, then interventional radiology needs to be consulted for an angiogram along with sub-selective embolization.
What is the Prognosis for Dieulafoy’s Lesion?
The death rate for Dieulafoy’s used to be higher before the advent of endoscopy (7). Previously the only treatment option for Dieulafoy’s lesion used to be open surgery; however, with today’s new treatment options, the prognosis of Dieulafoy’s lesion is good with long term controlling of the bleeding seen in about 85 to 90% of the patients (7).