Dieulafoy´s Lesion
Dieulafoy ulceration

Video Endoscopic Sequence 1 of 12.

Dieulafoy ulceration with large blood vessel

A 74-year-old female who had had multiple episodes of bleeding from the upper gastrointestinal tract with hematemesis and melena, in another city, had been diagnosed with this lesion presented in this image and video clip, later was referred to our endoscopic unit for specific treatment.

 A Dieulafoy ulcer is defined as a gastric ulcer with a massive hemorrhage from a shallow circular depression with an eroded artery in the center. The disease entity has been variously described as Dieulafoy ulcer, exulceratio simplex, gastric aneurysm or submucosal vascular malformation. 

Although relatively uncommon, Dieulafoy’s lesion is an important cause of acute gastrointestinal bleeding due to the frequent difficulty in its diagnosis; its tendency to cause severe, life-threatening, recurrent gastrointestinal bleeding; and its amenability to life-saving endoscopic therapy. Unlike normal vessels of the gastrointestinal tract which become progressively smaller in caliber peripherally, Dieulafoy’s lesions maintain a large caliber despite their peripheral, submucosal, location within gastrointestinal wall. Dieulafoy’s lesions typically present with severe, active, gastrointestinal bleeding, without prior symptoms; often cause hemodynamic instability and often require transfusion of multiple units of packed erythrocytes. About 75% of lesions are located in the stomach, with a marked proclivity of lesions within 6 cm of the gastroesophageal junction along the gastric lesser curve, but lesions can also occur in the duodenum and esophagus. Lesions in the jejunoileum or colorectum have been increasingly reported.

For more endoscopic details download the video clips by clicking on the endoscopic images, wait to be downloaded complete then press Alt and Enter; thus you can observe the video in full screen.

All endoscopic images shown in this Atlas contain
video clips.


Dieulafoy ulceration

Video Endoscopic Sequence 2 of 12.

As for any severe, acute, GI bleeding, pre-endoscopic therapy for a recently bleeding Dieulafoy’s lesion focuses on volume resuscitation to prevent systemic hypotension and consequent end-organ damage to heart, brain, or kidneys from hypoperfusion. Multiple, reliable, large-bore, intravenous lines are inserted. Volume resuscitation is initially performed with crystalline solution, with normal saline or Ringer’s lactate, but transfusion of packed erythrocytes is often required, after typing and crossing of blood, as guided by the tempo of the GI bleeding and serial hematocrit determinations. Patients with Dieulafoy’s lesions often require transfusion of three or more units of packed erythrocytes due to the severity of the bleeding. Electrolyte abnormalities are assessed and appropriately corrected. Treatment to reverse a severe coagulopathy is important before endoscopy, particularly when endoscopic therapy is contemplated.



Dieulafoy ulceration

Video Endoscopic Sequence 3 of 12.

It begins to practice infiltrations with pure histoacryl (n-butyl 2 cyanoacrylate). Because this vessel is large in size we decided to use this type of infiltration as a therapeutic strategy.

Therapeutic endoscopy for recently bleeding peptic ulcers depends upon the Forrest criteria, with endoscopic therapy recommended only for lesions that are actively bleeding or oozing, that have a visible vessel, or perhaps have an adherent clot[. Endoscopic therapy is not recommended for peptic ulcers that have a flat, pigmented spot or have a clean, homogeneous, flat base. Contrariwise, therapeutic endoscopy is recommended for virtually all Dieulafoy’s lesions, whether actively bleeding, oozing, or without any stigmata of recent bleeding. 

Therapeutic endoscopy is the primary treatment modality for acute GI bleeding. It can achieve initial hemostasis in about 90% of accessible lesions with a < 10% rate of rebleeding during the next 7 days.

Dieulafoy ulceration

Video Endoscopic Sequence 4 of 12.

Apparently the first 1.cc infiltration of the glue did not cause vessel ablation.

 The difference in therapeutic strategies reflects the natural history of Dieulafoy’s lesion as compared to peptic ulcers. Peptic ulcers with a flat pigmented spot have a low risk of rebleeding of about 8%-10% without endoscopic therapy and peptic ulcers with a clean, homogeneous, flat, base have only about a 3% risk of rebleeding without endoscopy therapy[. This low risk of rebleeding with these two types of peptic ulcers does not justify incurring the approximately 1% or more risk of major, life-threatening, complications from endoscopic therapy including, gastrointestinal perforation, massive bleeding, pulmonary aspiration, and cardiovascular complications[. In contrast, the risk of continued bleeding or rebleeding within 72 h from an untreated Dieulafoy’s lesion is very high. This high risk of rebleeding justifies undertaking the risks of therapeutic endoscopy to prevent further bleeding from Dieulafoy’s lesion.

 

Dieulafoy ulceration

Video Endoscopic Sequence 5 of 12.

The second dose of 1 cc of pure histoacryl is infiltrated.

The current modalities of endoscopic therapies include injection, ablation, and mechanical therapy. Injection therapy most commonly involves local injection of epinephrine, sclerosing agents (sclerotherapy), or cyanoacrylate. Epinephrine therapy promotes hemostasis via vasospasm and tamponade/mechanical pressure from interstitial injection that leads to stasis of blood and thrombus formation. Relative contraindications to epinephrine therapy may include severe tachycardia, cardiac arrhythmias such as atrial flutter, unstable vital signs from severe, uncorrected hypovolemia, and recent myocardial infarction or unstable angina. Sclerotherapy promotes vascular inflammation and thrombosis from local irritation, whereas cyanoacrylate promotes gluing to plug a bleeding artery. Ablation modalities include thermocoagulation, electrocoagulation, and argon plasma coagulation (APC). Photocoagulation using the yittrium aluminum garnet laser to ablate tissue has been discontinued due to an unacceptably high risk of gastrointestinal perforation. Ablation modalities can stem bleeding by destroying and devitalizing tissue. Thermocoagulation and electrocoagulation involve point contact with the lesion with apposition of the probe against the bleeding vessel. Contrariwise, APC involves hovering the probe over the lesion without lesion contact[. Mechanical therapy, including band ligation or endoscopic clips, can arrest bleeding by mechanically closing off the bleeding vessel. Mechanical therapy likely requires greater endoscopic skill and experience than injection or ablative therapies because correct placement of the band or clip directly around the lesion is critical for successfully strangulating the vessel within Dieulafoy’s lesion.

 

 

Dieulafoy ulceration

Video Endoscopic Sequence 6 of 12.

Status post-second infiltration, the patient was observed for 4 hours maintaining her vital signs stable.


Dieulafoy ulceration

Video Endoscopic Sequence 7 of 12.

The next day there was recurrence of bleeding, a second therapeutic endoscopy was performed.

 


 

Dieulafoy ulceration

Video Endoscopic Sequence 8 of 12.

Another infiltration of pure Histoacryl, this time using 2 cc.


 



Dieulafoy ulceration

Video Endoscopic Sequence 9 of 12.

The needle is seen inside the blood vessel



Dieulafoy ulceration

Video Endoscopic Sequence 10 of 12.

The glue is observed which has infiltrated the blood vessel of large diameter.



Dieulafoy ulceration

Video Endoscopic Sequence 11 of 12.

To perform hemostasis of the edges, Argon Plasma Coagulator is used

 

Dieulafoy ulceration

Video Endoscopic Sequence 12 of 12.

Final status of the therapy with glue,

The patient did not present no subsequent bleeding.

 

 

Dieulafoy´s Lesion (Exulceratio Simplex).

Video Endoscopic Sequence 1 of 6.

Dieulafoy´s Lesion (Exulceratio Simplex).

You must see the video clip.

Here, you can observe in the video clip an active arterial
bleeding. We recommend seeing it in full screen mode.

A 79-year-old female patient which had a bifemoral-aortic surgery (prosthesis) 25 days previously; a week before this procedure, she initiates with upper gastrointestinal bleeding, with hematemesis, melenic stools, paleness and hypotension. She was hospitalized and a emergency endoscopy practiced by another college was performed after a series of ice cold gastric lavage. Due to the active bleeding, it was impossible to diagnose during this endoscopy. 5 days later, after, the bleeding re-started, she received 4 unit of blood transfusions.

We performed a new endoscopy a day later using a more aggressive approach, we used the therapeutic endoscope, with double channel with a more suction power. After a successful aspiration of the blood and good maneuvering, then we were able to see the source of the bleeding. 

 

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 2 of 6.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

In order to make hemostasis, we used the Argon Plasma Coagulator (APC). It is important to notice that we experienced technical difficulties with the APC which gave us electrical interference with the video. The are several options to treat this ulcer, such as endoclips, band ligation as use in esophageal varices, alcohol injection, etc. For more information you can look for a similar case of Dieulafoy at the end of this chapter.

 

Image and video of the Dieulafoy´s Lesion

Video Endoscopic Sequence 3 of 6.

Image and video of the Dieulafoy´s Lesion


hemostasis performed by the Argon Plasma Coagulator (APC).

Dieulafoy, a French surgeon, described three cases in 1898, but the first case was in fact described by Gallard in 1884. Dieulafoy called the lesion “exulceratio simplex”, because of its small size, and because of the large underlying artery which was normal on histological examination. The lesion has also been given other names: calibre-persistent artery, gastric arteriosclerosis, cirsoid aneurysm, and submucosal arterial malformation. Dieulafoy’s lesion is inherently a difficult lesion to recognise, especially when bleeding is inactive. Nevertheless, it should be considered during the evaluation of any unexplained acute and recurrent major gastrointestinal bleeding.


Video Endoscopic Sequence 4 of 6.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

In this image and video you can observe the blood contents of the lesion.

 

Video Endoscopic Sequence 5 of 6.

Final status of the exulceratio simplex treated with APC.


Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 6 of 6.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Here you can observe part of the previous endoscopy practiced one day before where we almost discovered this lesion hidden beneath the blood clot.




Dieulafoy´s Lesion (Exulceratio Simplex).

Video Endoscopic Sequence 1 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex).

A 70 year-old female, who was hospitalized due to gastrointestinal hemorrhage.The image and video displaying here is a small ulceration in a gastric fold at the anterior wall of the proximal corpus. 



Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 2 of 11.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Dieulafoy´s Lesion is a vascular abnormality found almost exclusively in the proximal stomach that presents dramatically as acute and rapidly recurrent massive upper gastrointestinal hemorrhage when a small sub mucosal artery ruptures into the gastric lumen. Hemorrhage is caused by thrombosis and perforation of an abnormally large, tortuous sub mucosal artery in the center of a solitary 2- to 5-mm gastric mucosal erosion, surrounded by normal-appearing mucosa.



Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 3 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex)

A biopsy was taken, abnormal bleeding was noted. Dieulafoy´s varied endoscopic appearance includes active bleeding from a pinpoint mucosal defect, or a visible vessel containing adherent clot. Frequently, no endoscopic abnormalities are identified because of the small size of the lesion, the intermittent nature of its bleeding and the inability to visualize the bleeding point because of profuse hemorrhage.The diagnosis is often made only after repeated endoscopy or at the time of surgery or autopsy.


Dieulafoy´s Lesion (Exulceratio Simplex).

Video Endoscopic Sequence 4 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex).

The image and the video clip displays bleeding which should be cleaned.Although reports from the pre-endoscopic era suggested a mortality rate of up to 80% more recent series report mortality in less than 30% of cases.



Endoscopy of Dieulafoy´s Lesion (Exulceratio Simplex).

Video Endoscopic Sequence 5 of 11.

Endoscopy of Dieulafoy´s Lesion (Exulceratio Simplex).

Maneuvers of cleaner was made due to bleeding. Bleeding originates within 5 to 6 cm of the esophagogastric junction in 80% of cases.


Dieulafoy´s Lesion (Exulceratio Simplex).

Video Endoscopic Sequence 6 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex).

treat-ment. The specific therapeuticmodality used seems to depend on the availability andpersonal experience with a particular technique. Endoscopic therapy is said to be successful in achieving permanent haemostasis in 85% of cases. Of the remaining 15% in whom re-bleeding occurs, 10% cansuccessfully be treated by repeat endoscopic therapy and 5%may ultimately require surgical intervention Other studies havereported a higher success rate with endoscopic treat-ment, andsignificant decline of the need for laparotomy for both diagnosisand treatment. It must be emphasised, however, that anexperienced endoscopist and a reasonable selection oftherapeutic instruments are essential to achieve a high successrate. A Dieulafoy lesion can easily be over-looked, asconcomitant lesions such as ulcers or varices, may wrongly beconsidered responsible for the bleeding episode. Angiographymay also be used therapeutically by gelfaom embolisation.Thistype of treatment is usually reserved for patients who are notamenable to endoscopic therapy and are poor surgicalcandidates, if bleeding is still active.


Dieulafoy´s Lesion (Exulceratio Simplex).

Video Endoscopic Sequence 7 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex).

Therapeutical endoscopy using the argon plasma coagulator (APC).
The image and the video display the argon plasma coagulator beam inside of this lesion.

 

Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 8 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex).

More images and videos of therapeutical endoscopy using
the argon plasma coagulator (APC).



Video Endoscopic Sequence 9 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex).

Therapeutical endoscopy using the argon plasma
coagulator (APC).
The image is observed blurred due to smoke.


Dieulafoy´s Lesion (Exulceratio Simplex).

Video Endoscopic Sequence 10 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex).

Therapeutical endoscopy using the argon plasma
coagulator (APC).
Final status post argon plasma coagulation treatment.

 

Dieulafoy´s Lesion (Exulceratio Simplex).

Video Endoscopic Sequence 11 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex).

This picture and the video was taken 2 weeks after the
procedure with argon plasma. Status post treatment is
observed. The video displays a large submucosal vessel.

The rupture of a submucosal persistent-caliber artery,
named after the famous 19th century French surgeon as
Dieulafoy’s lesion, is now a well-recognized cause of
non-variceal upper gastrointestinal bleeding.

 

Dieulafoy´s Lesion (Exulceratio Simplex).

Video Endoscopic Sequence 1 of 9.

Dieulafoy´s Lesion (Exulceratio Simplex).

A 44 year-male, who was hospitalized in the emergency
room of Rosale´s Hospital in the Republic of El Salvador
(Public Hospital) because of hematemesis and melenas.
In that hospital an upper endoscopy was performed and two
unit of blood was transfused, three days after was
discharged from the hospital, the same day visit our
unit where a new endoscopy was performed here displayed.
His hemoglobin was 8.0 gr/dl. 


Video Endoscopic Sequence 2 of 9.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

We concluded that the bleeding became from this tiny
ulceration in the proximal third of the gastric body.

Similar lesions have also been described in the distal
esophagus, small intestine, colon, and rectum. Awareness
of the condition and experience in endoscopy are the
mainstay of diagnosis. Therapeutic endoscopy is the first
line of treatment. It is safe, effective and has very good
long term results.


Video Endoscopic Sequence 3 of 9.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

This tiny ulceracion which this upholstered with a
sanguineous clot.

Dieulafoy’s lesion is an uncommon cause of gastrointestinal
bleeding in which significant, and often recurrent,
hemorrhage occurs from a pinpoint non-ulcerated arterial
lesion.



Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 4 of 9.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

This time we decided to treat this clinical entity with
rubber bands.

Three rubber bands were applied.




Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 5 of 9.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Endoscopic injection therapy is another modality due to the
ease of use, the safety profile, and effectiveness. The
agents used include epinephrine, alcohol, ethanolamine,
cyanoacrylate glue, polidocanol, thrombin, and hypertonic
saline. Hypertonic saline or a mixture of epinephrine and
saline are the most commonly used agents and work by
local tamponade or tamponade/local vasoconstriction,
respectively.


Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 6 of 9.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

The identification of high-risk stigmata of hemorrhage
enables selective targeting of endoscopic therapy to lesions
at high risk of rebleeding. Advances in technologies such
as novel mechanical methods of hemostasis (eg, metallic
clips), injection techniques (eg, cyanoacrylate injection),
and the widening application of established endoscopic
hemostatic techniques (eg, rubber-band ligation) to lesions
offers the possibility of further improvements in the
efficacy of endoscopic hemostasis.

 

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 7 of 9.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Multiple conventional methods for achieving hemostasis
have been used effectively. These include thermal methods
(such as monopolar/bipolar cautery), heater probe, injection
therapy, combination injection/thermal therapy, and laser
therapy (argon and neodymium-yttrium aluminum garnet
[Nd:YAG]). Of these current methods, no one method or
combination has been shown to be superior for hemostatic
control.



Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 8 of 9.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Endoscopic thermal coagulation is most often administered
with monopolar, bipolar, or multipolar heater probes and
laser. Monopolar, bipolar, multipolar, and heater probes
work by coagulating and coapting the blood vessels
supplying the mucosa. Physical compression and
tamponade of the vessel are essential to ensure optimal
effectiveness of this modality.


Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 9 of 9.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

In this image as well as the video clip, the final status of
ligation is displayed.

 

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 1 of 8.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

This 84 year-old lady who 3 week previously undergone a hip surgery due to a fracture, presented an upper gastrointestinal tract hemorrhage with hematemesis and melena.

The image and the video clips show a large blood clot in the lower third of the esophagus.



Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 2 of 8.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

More images and video clips.

 

 

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 3 of 8.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Active bleeding due to Dieulafoy´s Lesion 

Video Endoscopic Sequence 4 of 8.

Active bleeding due to Dieulafoy´s Lesion 

The retroflexed image shows an ulcer with a large vessel in
the proximal body, Approximately 75% to 95% of
Dieulafoy lesions are found within 6 cm of the
gastroesophageal junction, predominantly on the lesser
curve. The blood supply to that portion of the stomach is
from a large submucosal artery arising directly from the
left gastric artery. Lesions of similar morphological and
histological features have been found in the distal
esophagus, the duodenal bulb the jejunum the colon and the rectum.


Active bleeding due to Dieulafoy´s Lesion 

Video Endoscopic Sequence 5 of 8.

The upper gastrointestinal bleeding by Dieulafoy’s lesion is
a rare cause of bleeding, it is a massive hemorrhage and it
is difficult to diagnose. Endoscopy is the diagnostic method
of choice, in many cases are necessary repeated
examinations.
Therapeutic endoscopy is the first line of treatment. It is
safe, effective and has very good long term results.

 

Active bleeding due to Dieulafoy´s Lesion 

Video Endoscopic Sequence 6 of 8.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Immediately a hemostasis was carry out with absolute alcohol injection. 

Active bleeding due to Dieulafoy´s Lesion 

Video Endoscopic Sequence 7 of 8.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Pathogenesis

The consensus seems to be that it is caused by an
abnormally large-calibre persistent tortuous submucosal
artery. This has been demonstrated by histological
examination of resected specimens and by postmortem
examinations.


Active bleeding due to Dieulafoy´s Lesion 

Video Endoscopic Sequence 8 of 8.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Successful treatment of a gastric Dieulafoy's lesion with absolute alcohol.

Endoscopic therapy is said to be successful in achieving
permanent hemostasis in 85% of cases. Of the remaining
15% in whom re-bleeding occurs, 10% can successfully be
treated by repeat endoscopic therapy and 5% may
ultimately require surgical intervention.


Active bleeding due to Dieulafoy´s Lesion 

Video Endoscopic Sequence 1 of 7.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

This 75-year-old female, has been hospitalized in 4
occasions because of upper gastrointestinal bleeding in a
national hospital but it seem that she not got any
therapeutical treatment, was referred to our endoscopic
unit for specific treatment.


Active bleeding due to Dieulafoy´s Lesion 

Video Endoscopic Sequence 2 of 7.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

The image as well as the vídeo clip; at seven o'clock, it shown abundant red brilliant blood.



Active bleeding due to Dieulafoy´s Lesion 

Video Endoscopic Sequence 3 of 7.

Dieulafoy´s Lesion (Exulceratio Simplex).

Actively bleeding the ulcer


 

Active bleeding due to Dieulafoy´s Lesion 

Video Endoscopic Sequence 4 of 7.

Dieulafoy´s Lesion (Exulceratio Simplex).

 

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 5 of 7.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Immediately a hemostatic therapy with banding was carried out.

 

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 6 of 7.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

The image as well as the video clip show the bands that have been strangulated the bleeding area.


Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Video Endoscopic Sequence 7 of 7.

Endoscopy of a Dieulafoy´s Lesion (Exulceratio Simplex)

Final Status of the Successful Therapy of Dieulafoy´s Lesion (Exulceratio Simplex).


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