Life-threatening upper gastrointestinal bleeding due to gastric Dieulafoy's lesion: Successful minimally-invasive management.

Dieulafoy's lesion (DL) is a relatively rare, but potentially life-threatening condition. It accounts for 1-2% of acute gastrointestinal bleedings. Its serious nature makes it necessary for early diagnosis and treatment. This is a case report of a patient who presented with life-threatening haematemesis due to gastric Dieulafoy's that was successfully treated laparoscopically after failed endotherapy.

INTRODUCTION

Gallard in 1884 described Dieulafoy's lesions (DLs) as a ‘military aneurysm’.[1] In 1898, Dieulafoy, a French surgeon, referred to these lesions as exulceratio simplex and felt that these were the result of injury to the gastric mucosa with subsequent haemorrhage from a normal submucosal artery.[2] DL is a persistent calibre artery anomaly that is relatively rare yet possibly fatal because of gastrointestinal bleeding. Advances in endoscopic technique have greatly assisted in early diagnosis and added various options for the treatment for this lesion. However, patients with failed endotherapy at times require rescue surgery to achieve haemostasis.

CASE

A 51-year-old male patient had massive haematemesis and presented to us in hypovolemic shock. The patient had a body mass index (BMI) of 28, had multiple comorbidities including uncontrolled diabetes, hypertension and hypercholesterolemia. He was not on any antiplatelet medication or nonsteroidal anti-inflammatory drugs (NSAIDs). In addition, he gave a history of social consumption of alcohol. Routine biochemistry was within normal limits except for anaemia. Emergency gastroscopy was done. It showed a dilated tortuous vessel in the gastric fundus with active spurting from a superficial ulcer overlying it. Possibility of isolated gastric varices was considered and cyanoacrylate glue was injected. However, within 48 h, the patient had a repeat bout of haematemesis for which repeat endoscopy and glue injection was done. Computed tomography (CT) of the abdomen with CT angiography failed to reveal any obvious focus of bleeding. Check endoscopy done after 72 h did not show any active oozing from the vessel. The patients had a further bout of massive haematemesis on the 5th day, wherein a surgical consultation was sought. A differential diagnosis of DL was strongly considered and urgent surgical intervention was done. At laparoscopy, wedge resection of the fundus was done using staplers and final histopathology diagnosis was consistent with a DL. The patient was fed 72 h after a gastrografin failed to demonstrate a leak and then discharged and is well at follow-up.

DISCUSSION

Paul Georges Dieulafoy (1839-1911), a Professor of Pathology in Paris, France was the first to describe a series of patients who presented with massive haematemesis due to a bleeding gastric vessel without any evidence of ulceration at autopsy.[2] DL is histologically a normal vessel with an abnormally large diameter maintaining a consistent width of 1-3 mm. It runs a tortuous course within the submucosa and typically the lesion protrudes through a small mucosal defect varying from 2-5 mm with fibrinoid necrosis at its base. The fundus of the stomach within 6 cm of the cardia on the lesser curvature is the most common site for DL. This is attributed to the architecture of blood supply to the lesser curve of the stomach as vessels arise directly from the arterial chain. In the remainder of the stomach, the blood supply is derived from submucosal plexus of large vessels.

The aetiology of DL is still uncertain. They are twice as common in males as females, more commonly seen in the elderly population. Associated comorbidities are present in more than 50% of patients, most frequently cardiac and renal diseases.

Initial endoscopy is effective in diagnosing up to 70% of patients. Failure to diagnose DL is often attributed to excessive blood or the fact that the lesion was subtle and hence, overlooked. Endoscopic ultrasound can aid in the diagnosis and additionally bleed provocation test by intravenous (IV) heparin bolus. Characteristic endoscopic findings include isolated protruding vessel surrounded by normal mucosa, which does not have an associated ulcer. In actively bleeding lesions, blood could be seen spurting or oozing from the pinpoint defect. In the absence of bleeding, a clot without an ulcer might be seen.[3] Meticulous inspection of the gastric mucosa, especially in the well distended upper part of the stomach, is essential for an adequate diagnosis.

Endoscopic therapy is usually successful in achieving primary haemostasis; with success rates reaching 75-100%. Treatment options are dependent on the mode of presentation, site of the lesion and availability of expertise. Endoscopic haemostatic procedures can be classified into three groups, thermal [heater probe, argon plasma coagulation (APC)], regional (adrenaline, sclerosants) and mechanical (bands or hemoclips).[3]

Combination endoscopic therapy is known to be superior to monotherapy because of the lower rate of recurrent bleeding. Mechanical therapies including hemoclips and band ligation are more effective and successful in controlling bleeding than other methods. Advances in endoscopic therapy have reduced mortality in patients with DL from 80% to 8%. Indications for selective angiography include failed endoscopic therapy, lesions beyond the reach of therapeutic endoscope and poor candidates for surgery. Additionally, embolisation carries a risk of ischemia to the area supplied by the relevant artery.

Surgical treatment was historically the first line of treatment for DL of the stomach in the form of gastrectomy. This has now been overtaken by advances in endoscopic procedures. Surgical resection is currently reserved for 5% of cases that are refractory to endoscopic or angiographic measures. Currently, minimal invasive surgery has been shown to play a greater role in the surgical management of a DL that fails endoscopic treatment. Intraoperative or preoperative endoscopy has been used for localisation and laparoscopic resection of DL has been successfully performed.[456] Real-time operative endoscopy with picture-in-picture viewing is a powerful surgical tool allowing for simultaneous intra and extraluminal views. The endoscopic view allows for haemostasis to be ensured and for precise anatomical excisions to be performed, especially in cases requiring preservation of the pylorus.[7]

In this case, as the lesional haematoma and the subsequent attempts at endoscopic control left a serosal mark, endoscopic intraoperative localisation was unnecessary. Plus, the endoscopic video provided a fairly accurate localisation of the bleeding site. In cases, as in this, when one suspects or sees proximity to the gastroesophageal (GE) junction, it is advisable to place a bougie or calibration tube in the oesophagus to prevent narrowing the gastric inlet, as we do in any stapling near the GE junction. In cases of prior glue injection, the surgeon has to be careful to avoid stapling on the glued site to prevent jamming the stapler or breaking the blade.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.