Dieulafoy's lesion

Dieulafoy's lesion is a rare but potentially life-threatening medical condition characterized by the presence of a large, tortuous arteriole in the submucosa of the stomach, which can lead to significant gastrointestinal bleeding. This condition was first described by the French physician Paul Georges Dieulafoy in 1898 and is sometimes referred to as "exulceratio simplex Dieulafoy."

Etiology and Pathophysiology

The exact cause of Dieulafoy's lesion remains unclear, but it is not associated with underlying diseases or conditions that affect blood vessels. The lesion consists of a dilated, aberrant submucosal artery that protrudes through a small defect in the mucosa. Unlike peptic ulcers, there is no significant inflammatory or ulcerative process surrounding the vessel. The high pressure within this abnormal artery can lead to rupture and severe bleeding into the gastrointestinal tract.

Clinical Presentation

Patients with Dieulafoy's lesion typically present with sudden and often severe gastrointestinal bleeding. The bleeding can be intermittent, making the diagnosis challenging. Common symptoms include hematemesis (vomiting blood), melena (black, tarry stools), or hematochezia (passing fresh blood per rectum) in severe cases. The condition can occur at any age but is more common in middle-aged and elderly individuals. There is no clear gender predilection.

Diagnosis

The diagnosis of Dieulafoy's lesion is primarily endoscopic. Upper gastrointestinal endoscopy is the diagnostic modality of choice and can also serve as a therapeutic intervention. During endoscopy, the characteristic appearance of a protruding vessel within a small mucosal defect without surrounding ulceration is identified. However, due to the intermittent nature of bleeding and the small size of the lesion, multiple endoscopies may be required for diagnosis.

Treatment

The primary goal in managing Dieulafoy's lesion is to control bleeding and prevent rebleeding. Endoscopic treatments are the first-line therapy and may include:

• Endoscopic band ligation
• Endoscopic sclerotherapy
• Thermal coagulation
• Hemoclipping

In cases where endoscopic treatment is unsuccessful or not feasible, angiographic embolization of the bleeding vessel or surgical intervention may be required. Surgical options include local excision of the lesion or more extensive procedures depending on the lesion's location and the patient's overall condition.

Prognosis

With prompt diagnosis and appropriate treatment, the prognosis for patients with Dieulafoy's lesion is generally good. However, the risk of rebleeding exists, and close follow-up is necessary. Mortality is primarily related to the severity of the initial bleeding episode and the presence of comorbid conditions.

Epidemiology

Dieulafoy's lesion is responsible for approximately 1-2% of cases of acute gastrointestinal bleeding. It can occur anywhere along the gastrointestinal tract but is most commonly found in the proximal stomach.

See Also

• Gastrointestinal bleeding
• Endoscopy
• Peptic ulcer