Odysseys of George

A lady in her late 40s presented with passing black tarry foul smelling stools (malaena) for a few days prior to admission. This was the second episode after the first being a few days earlier.She was admitted then but was discharged home on a negative finding on endoscopy. On the day of admission, she fainted at home after complaining of feeling lightheaded.

She was admitted and an urgent upper endoscopy was performed. As we were about to withdraw the scope in disappointment, I caught a glimpse of this near the fundus and got excited!

Any takers?
The man responsible has my name too! Ha Ha Ha
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Named after French surgeon Paul Georges Dieulafoy, who described this condition in his paper “Exulceratio simplex: Leçons 1-3″ in 1898, Dieulafoy’s lesion is an uncommon cause of gastric bleeding thought to cause less than 5% of all gastrointestinal bleeds in adults.

It is also called “Caliber-persistent artery” or “Aneurysm” of gastric vessels but unlike a true aneurysm it is thought to be due to a developmental malformation rather than a degenerative change.

So what is this Dieulafoy’s lesion?

Dieulafoy’s Lesions(DL) is characterized by a single large tortuous arteriole in the submucosa which does not undergo normal branching, or one of the branches retain high calibre of about 1-5 mm which is more than 10 times the normal diameter of mucosal capillaries. The lesion bleeds into the gastrointestinal tract through a minute defect in the mucosa which is not a primary ulcer of the mucosa but an erosion probably caused from the submucosal surface by the pulsatile arteriole protruding into the mucosa.

95% of Dieulafoy’s lesions occur in the upper part of the stomach, within 6 cm of the gastroesophageal junction commonly in the lesser curvature, however they can occur anywhere in the GI tract.

Extragastric DLs are uncommon, but have been identified more frequently in recent years because of increased awareness of the condition. Duodenum is the commonest location(18%) followed by colon(10%) and jejunum(2%) and esophagus(2%). The pathology of the lesion is essentially the same.

Interestingly and in contrast to peptic ulcer disease, a history of alcohol abuse or NSAID use is usually absent in Dieulafoy’s.

So what did we do?

Yes, we clipped it and she was well thereafter. Therapeutic endoscopy is the treatment of choice. It is safe, effective and achieves very good long-term results.

Ref:
1.Dieulafoy G. L’exulceratio simple. In Manuel de Pathologie Interne. Paris, Masson, 1908, 178-305

2. Strong R. Dieulafoy disease: A distinct clinical entity. Aust N Z J Sur 1984; 54: 337-9

3. Squilace SJ, Johnson DA, Sanowski RA. The endoscopic appearance of a Dieulafoy’s lesion. Am J Gastroenterol 1994; 89: 276-7

4. Stark ME, Gostout CJ, Balm RK. Clinical features and endoscopic management of Dieulafoy disease. Gastrointest Endosc 1992; 38: 545-50

5. Wikipedia.

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