Dieulafoy lesions as cause of upper gastrointestinal bleeding in a patient with portal hypertension.

Dieulafoy's lesion is an abnormally large and tortuous submucosal artery that protrudes through a small mucosal defect resulting in gastrointestinal bleeding. We present a case of a 53-year-old man with a history of HIV and alcohol abuse who presented to the emergency room with hematemesis and melena. Upper endoscopy revealed an actively bleeding dieulafoy lesion, but due to uncontrolled bleeding, embolization of the left artery was necessitated. The incidence of dieulafoy lesions is about 0.3% to 6.7% within the stomach. The etiology remains uncertain but has been linked to alcoholism and antiplatelet drugs. We are emphasizing the importance of considering uncommon causes of upper gastrointestinal bleeding in patients with portal hypertension.

Case history

A 53-year-old man with a history of HIV and alcohol abuse presented to the emergency room with episodes of hematemesis and melena. Patient was taking naproxen almost daily for his chronic knee pain. He had pallor, tachycardia, orthostatic hypotension and black stools on rectal examination. His hemoglobin was 7.8 g/dl and platelet count was 115,000. Intravenous fluids, octreotide and packed red blood cells were given. Abdominal ultrasound revealed cirrhosis with high portal pressure. Upper endoscopy detected an actively bleeding gastroesophageal dieulafoy lesion that was bleeding uncontrollably, which necessitated the embolization of the left gastric artery. Hemoclips and epinephrine injections failed to control bleeding. An abdominal angiogram with coil embolization was performed, which successfully stopped the bleeding [Figure 1and Figure 2].

Figure 1.

Abdominal Angiogram Pre-embolization: The area of active contrast extravasation(arrow) demonstrated in distal part of left gastric artery

Figure 2.

Abdominal Angiogram Post-embolization: The celiac angiography demonstrating effective coil embolization of the mid-left gastric artery with no more contrast extravasation (arrow)

Discussion

Dieulafoy’s lesion is an abnormal, large and tortuous submucosal artery that protrudes through a mucosal defect and results in bleeding, with an incidence rate of 0.3% to 6.7%. The etiology remains uncertain but has been linked to alcoholism and antiplatelet drugs [1,2]. Effective homeostatic modalities include: endoscopy with a combination of epinephrine injection followed by probe coagulation, hemoclip placement, angiographic embolization, or surgery [3]. Angiography is the next best step in management if endoscopic methods fail [4]. This case emphasizes the importance of considering uncommon causes of upper gastrointestinal bleeding in patients with portal hypertension and concomitant nonsteroidal anti-inflammatory drug use.