Search

Objective: Dieulafoy's lesions (DLs) are a rare but potentially life-threatening source of gastrointestinal (GI) haemorrhage. They are responsible for roughly 1%-6.5% of all cases of acute non-variceal GI bleeding.Here, we describe retrospectively the clinical and endoscopic features, review the short-term and long-term outcomes of endoscopic management of bleeding DLs and we identify rate and risk factors, of recurrence and mortality in our endoscopic unit., Design: Data were collected from patients presenting with GI haemorrhagic secondary to DLs between January 2018 and August 2023. Patients' medical records as well as endoscopic databases were retrospectively reviewed. Demographic data, risk factors, bleeding site, outcomes of endoscopy techniques, recurrence and mortality rate were taken into account., Results: Among 1170 cases of GI bleeding, we identified only seven cases involving DLs. Median age was 74 years, with a male-to-female ratio of 2.5. 75% of patients had significant comorbidities, mainly cardiovascular diseases. Only anticoagulant and antiplatelet agents were significantly associated with DLs. All patients were presented with GI bleeding as their initial symptom. The initial endoscopy led to a diagnosis in 85% of the cases. Initial haemostasis was obtained in all patients treated endoscopically. Nevertheless, the study revealed early recurrence in two out of three patients treated solely with epinephrine injection or argon plasma coagulation. In contrast, one of three patients who received combined therapy, experienced late recurrence (average follow-up of 1 year). Pathological diagnosis was necessary in one case. One patient (14%) died of haemorrhagic shock. Average length of hospital stay was 3 days., Conclusion: Although rare, DLs may be responsible for active, recurrent and unexplained GI bleeding. Thanks to the emergence of endoscopic therapies, the recurrence rate has decreased and the prognosis has highly improved. Therefore, the endoscopic approach remains the first choice to manage bleeding DLs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To analyze the possible differential features of upper gastrointestinal (GI) bleeding due to Dieulafoy's lesion (DL) compared with bleeding due to gastroduodenal ulcer., Material and Methods: We evaluated variables associated with patient characteristics, hemorrhagic characteristics and clinical severity in 31 cases of bleeding secondary to DL and 31 cases of gastroduodenal ulcer bleeding. Univariate and multivariate statistical analysis were performed., Results: The comorbidity rate was 80% in the DL group and 42% in the ulcer group (OR = 5.54; 95%CI, 1.5-20.7; p < 0.0004). Lesion location was gastric in 87% of DL versus 39% of ulcers (OR = 10.7; 95%CI, 2.6-47.6; p < 0.0003). More than one gastroscopy was required for diagnosis in 30% of DL vs. 3.2% of ulcers (OR = 12.9; 95%CI, 1.4-291; p < 0.01). Endoscopic treatment was required in 97% of DL and 39% of ulcers (OR = 47.5; 95%CI, 5.5-106.1; p < 0.0001). Active bleeding during endoscopy was registered in 81% of DL and in 29% of ulcers (OR = 10.2; 95%CI, 2.7-40.3; p < 0.0005). The remaining variables analyzed showed no significant differences. The mortality rate was 9.7% in the DL group and 3.2% in the ulcer group (p = NS). Multivariate analysis showed that gastric location (p < 0.01), active bleeding (p < 0.01), and comorbidity (p < 0.02) were more frequent in DL., Conclusions: Active bleeding and gastric location of the lesion were more frequent in the DL group than in the ulcer group. Diagnosis of DL is difficult, requiring a greater number of gastroscopies. Initial hemorrhage severity and the success rate of endoscopic treatment were similar in the two groups. The higher mortality found in DL can be explained by the greater comorbidity in these patients, with a worse bleeding tolerance.

Endoscopy has become the first and primary diagnostic and therapeutic modality in the management of patients with severe gastrointestinal bleeding. Panendoscopy, push enteroscopy, and colonoscopy provide the diagnostic, prognostic, and therapeutic elements to improve patient outcomes and to reduce morbidity and mortality from severe GI hemorrhage. Recent improvements in endoscopic hemostatic techniques and in imaging modalities using wireless capsule endoscopy suggest that diagnostic and therapeutic endoscopy will be even more important in determining patient outcomes in the future.

Objective: The authors report their experience about the endoscopic treatment of upper gastrointestinal bleeding from Dieulatoy's ulcer (non variceal bleeding)., Design: Report of 5 cases; evaluation of mortality and effectiveness of the treatment., Setting: Operative Unit of General and Thoracic Surgery, Department of Surgical, Anatomical and Oncological Disciplines. Policlinico, University of Palermo., Interventions: EGDS + sclerotherapy (emergency room) in all 5 patients., Results: 80% successful (stop bleeding)., Conclusions: Endoscopic sclerotherapy is choice treatment of upper gastrointestinal bleeding from Dieulafoy's ulcer, only in well experienced teams and rapidly.

Recurrent bleeding from an obscure gastrointestinal source is a common but often frustrating clinical challenge. Frequently these bleeds can be attributed to vascular anomalies in the upper or lower gastrointestinal tract. Traditional management has included surgical resection and endoscopic fulguration. However, these methods are often ineffective when vascular lesions are diffuse, difficult to identify, or endoscopically inaccessible. Hormone therapy with a combination of oestrogen and progesterone represents a promising alternative. Since initial reports of success in patients with epistaxis from hereditary haemorrhagic telangiectasia, growing evidence supports its role in reducing bleeding from gastrointestinal vascular anomalies. Existing literature is critically reviewed and management strategies incorporating hormone therapy are suggested.

conventional endoscopic procedures do not allow direct visual access to the small bowel. Small bowel bleeding can be investigated by enteroclysis, radionuclide bleeding scan and angiography of the mesenteric artery. However, localization of the bleeding can only be determined with these diagnostic tools in 15% of cases. A case of small bowel bleeding diagnosis by enteroscopy is presented, followed by an overview of the literature related to this novel endoscopic technic.

The Dieulafoy gastric malformation is a rare cause of upper gastrointestinal haemorrhage. When no obvious bleeding lesion is seen at laparotomy this diagnosis ought to be considered. Three such cases were identified and treated with simple underrunning of the lesion with no mortality and minimal morbidity. Follow-up endoscopy in each patient showed complete healing of the lesion.

8 cases of gastrointestinal angiodysplasia are reported. It can be stated on the analysis of these cases, that the angiodysplasia can be the cause of unexplained GI hemorrhages, and in the majority of cases the visceral angiography provides diagnostic evidence. The angiodysplasia can be observed frequently in association with liver cirrhosis and aortic valvular stenosis. Surgery is regarded as the best method of treatment. Subsequently the careful resection rebleeding and development of newer angiodysplasia can occur.

After a review of recent literature on angiodysplasias of the digestive system, a diagnostic procedure based on personal experience is proposed for haemorrhagic patients. Criteria for the selection of treatment protocols are then proposed for cases where angiodysplasia is recognised as the cause of the bleeding.

Angiodysplasia of the colon is a relatively common cause of blood loss in the elderly. Electrocoagulation through a colonoscope is a common mode of treatment for this condition. Three patients are presented who had associated hemostatic defects and electrocoagulation resulted in life threatening secondary hemorrhage. In two of these patients a right hemicolectomy was performed. On the basis of these findings we suggest that patients with angiodysplasia and associated hemostatic disorders have a greatly increased risk of secondary hemorrhage following electrocoagulation treatment. These patients should be followed closely for two-three weeks following this treatment.

Urgent surgical operation to treat massive hemmorrhage of colorectal origin was necessary in 12 patients: --colon diverticulosis: 7 cases, --cecal angiodysplasia: 1 case, --pancreatocolic fistula: 1 case, --ischemic colitis: 2 cases, --post-radiation therapy rectitis: 1 case. Lesions exclused from discussion in this report and provoking hemorrhage were colorectal tumors, chronic inflammatsry colitis, rectosigmoid angiomatosis, and post-traumatic or iatrogenic lesions. After a definition of massive hemmorrhage based on pre-operative transfusional requirements, the exploratory procedures necessary for localization of the site of the hemorrhage or for detecting a right colon angiodysplasia are discussed. Bimesenteric arteriography represents the exploration of choice, but its usefulness is limited in patients with several risk factors and an average age of 70 years. The respective values of a barium enema and peroperative endoscopy in this particular context are also discussed. Elective surgery should be performed only when the exact site of bleeding has been determined or when an angiodysplasia is present. Particular problems arise when treating diffuse colon diverticulosis hemorrhage, and that provoked by the association of an angiodysplasia and a diverticulosis, as well as hemorrhagic lesions that may require emergency therapy in much rarer affections: ischemic colitis, pancreatocolic fistula, iliosigmoidal fistula, colorectal varices, colon and rectal ulcers, and colorectal radiolesions.

Twelve patients with angiodysplasia of the gastrointestinal tract were seen at The Mary Imogene Bassett Hospital are presented. Six share the features of gastric or duodenal angiodysplasia, advanced age, and aortic valve disease. Of these 6 patients, 4 who bled repeatedly were treated with endoscopic coagulation of areas of gastric and duodenal angiodysplasia. Six patients with other types of gastrointestinal angiodysplasia are presented for comparison. Two had gastric angiodysplasia and no aortic valve disease, 2 had hereditary hemorrhagic telangiectasia, 1 had received irradiation, and 1 could not be classified. We suggest that angiodysplasia of the gastrointestinal tract can be regarded as a spectrum with a clearly inherited etiology on one extreme and an acquired etiology on the other. A subset of these patients may be associated with aortic valve disease. Angiodysplasia of the upper gastrointestinal tract may account for a significant fraction of previously unexplained bleeding. It is hoped that this paper will aid in their more frequent recognition.

13 observations of right hemorrhagic colic angiodysplasia were detected in less than 5 years: 9 times with proctorrhagia of varying amounts, 4 times with an endoscopic aetiological evaluation of iron deficiency anemia. Colonoscopy revealed lesions in 11 patients out of 13 in the form of erythematous spots of vascular hemorrhagic appearance in 5 cases. The arteriography was positive in 5 of the 7 cases where it was performed. Treatment was endoscopic 6 times, by follow-up electrocoagulation, 2 times, by right hemicolectomy. The latter was carried out immediately in 2 other cases. In 5 cases, iron treatment was all that was necessary. These right colic angiodysplasias are often an unknown cause of digestive hemorrhage or iron deficiency anemia. The difficult diagnosis depends on the colonoscopy performed by an operator accustomed to this type of lesion. It is carried out in emergency in cases of acute bleeding. Sometimes an arteriography is also performed. Endoscopic treatment may be an alternative to standard surgical treatment in elderly high-risk patients.

Of 34 patients with massive lower intestinal bleeding, 17 (11 men and 6 women, age range 33-85 years; mean 64.8 years) were diagnosed as having angiodysplasia of the colon. The diagnosis was made by colonoscopy and the lesions were treated successfully by fulguration in 13 (86.6 per cent) of 15 patients. Two of the 17 patients underwent surgical resection of the involved intestinal segment. One patient still has sporadic intestinal haemorrhage, and another patient died from bleeding of the left colon after blind right colectomy. The remaining 13 patients have had no further bleeding in the 1-7 years following colonoscopic fulguration. Colonoscopy is a useful method of diagnosing angiodysplasia of the colon and affords the possibility of treatment.

Angiography has become an integral tool in the management of patients with gastrointestinal bleeding. It is used for localizing the site of bleeding and then for controlling the bleeding when more conservative methods of treatment are unsuccessful.

Three patients who bled from curious vascular lesions of the gastric antrum are described. Each presented with an iron-deficiency anemia. Histological examination in two of the patients demonstrated numerous ectatic submucosal vessels in the antrum, the appearances being somewhat similar to angiodysplasia of the colon. The gastric lesions were not shown by barium meal examination or angiography but gave characteristic appearances on endoscopy. We believe that Billroth I partial gastrectomy is the treatment of choice for this condition.

Recurrent gastrointestinal bleeding ceased after the institution of estrogen-progesterone therapy in a patient with gastrointestinal angiodysplasia without chronic renal failure. The patient did have aortic stenosis and mitral insufficiency murmurs. A therapeutic trial of conjugated estrogen should be considered in patients with recurrent gastrointestinal bleeding secondary to gastrointestinal angiodysplasia after the use of therapeutic endoscopy and/or surgery.

Angiodysplasia of the colon with preferential localisation in the region the ileocoecal valve is not infrequently the cause of massive gastrointestinal bleeding. The diagnostic problems of this disease are illustrated by seven cases. Contrary to angiography, coloscopy, which may have to be done as an emergency procedure, frequently does not allow localisation of the haemorrhage. Vascular malformations can be demonstrated by arteriography even in the asymptomatic interval. They frequently escape macroscopic identification even in the resected specimen due to their small size and their localisation in the submucosa. The diagnosis can be established histologically by serial sections with vascular filling if necessary. The treatment of choice is resection of the affected part of the gut. In cases of decreased operability endoscopic laser coagulation can be indicated.

Angiodysplasia of the colon is increasingly recognized as a cause of obscure gastrointestinal haemorrhage. On review of 71 patients with angiodysplasia, 40 came to surgery. Of these, nine (22.5 per cent) were also found to have small bowel lesions, either at the original laparotomy (7) or later when further investigations were performed for recurrent bleeding. Angiodysplasia can only be confidently diagnosed as the source of blood loss if seen to be actively bleeding. If a synchronous small bowel lesion is seen, we recommend that it should be removed at the same time as the colectomy.

The cases are presented of 9 patients with intestinal angiodysplasia observed in 1979-85 in the surgery departments of San Carlo Borromeo Hospital, Milan. Diagnostic problems are discussed with particular reference to angiographic and endoscopic methods. Surgical treatment gave good results. Recurrent bleeding may depend on the inadequate assessment of the extension of the lesion or on the existence of other unrecognised intestinal sites.

We report a female infant who presented at birth with an unusual syndrome of disseminated cutaneous and gastrointestinal vascular malformations associated with severe thrombocytopenia and chronic gastrointestinal hemorrhage. The infant required extensive blood-product support and expired at 7 months of age. Postmortem examination confirmed the presence of numerous flat vascular lesions, descriptively classified as angiodysplastic, and composed of congeries of dilated capillaries, arterioles, and postcapillary venules. No visceral space-occupying hemangiomas were found. The case is discussed in relation to a spectrum of congenital vascular malformation syndromes including disseminated neonatal hemangiomatosis and hereditary hemorrhagic telangiectasia (HHT). Some pathologic characteristics appear to link it to the latter entity. However, other clinical and pathologic features distinguish it from the reported spectrum of congenital HHT, prompting its essentially descriptive designation.

Modern diagnostic techniques have led to increased accuracy in the diagnosis of gastrointestinal bleeding. Occasionally, however, the source of bleeding remains obscure. A careful, step-wise approach, is required to provide a diagnosis in these cases.

The observation by Heyde that unexplained gastrointestinal bleeding may be associated with aortic stenosis has been confirmed by many others. It has been suggested that the combination of gastrointestinal bleeding and aortic stenosis be termed Heyde's syndrome. Gastrointestinal bleeding in this syndrome has been attributed to angiodysplasia. Segmental resection of those portions of the gastrointestinal tract containing the angiodysplastic lesions has been considered the definitive treatment for patients with Heyde's syndrome who are symptomatic because of chronic blood loss. However, recent observations suggest that aortic valve replacement with a bioprosthesis is a better therapeutic approach for those patients with severe aortic stenosis. This treatment has been shown to alleviate the symptomatology of both the stenosed aortic valve and the chronically bleeding bowel.

Within a two-year period, 12 patients with upper gastrointestinal bleeding due to gastroduodenal vascular malformations were admitted to a specialized intensive care unit. They represented 2.1% of all admissions for upper gastrointestinal bleeding, and 3.7% of those with severe hemorrhage (greater than or equal to 2 units of blood transfused). Early endoscopy was nondiagnostic during the first bleeding episode in all nine patients with nonhereditary vascular malformations; the diagnosis was eventually made after relapsing hemorrhage by repeat endoscopy in five patients, angiography in two, and histology in another two. These nine patients accounted for 23.6% of all cases of upper gastrointestinal bleeding considered to be of unknown origin after initial work-up. The remaining three patients had Rendu-Osler-Weber disease, and the first endoscopy was diagnostic in all of them. Emergency treatment was required for 11 patients; surgery was undertaken in seven, and transendoscopic therapy (electrocoagulation or endoscopic clipping) in four. There was a 25% mortality rate. No further bleeding has occurred in eight patients after a mean follow-up period of two years. Gastroduodenal vascular malformations are a more frequent cause of upper gastrointestinal bleeding than heretofore recognized, especially in patients whose hemorrhage is deemed to be of unknown origin after an initial work-up. Endoscopy, which may need to be repeated, is the most rewarding diagnostic procedure. Awareness of their possible existence facilitates endoscopic recognition. When available, transendoscopic therapy is a good choice to stop active bleeding from such lesions.

Angiography has added a new dimension to the management of hemorrhage from the large bowel. In patients with diverticular hemorrhage, mesenteric angiography not only localizes the bleeding site but, in addition, the bleeding can be acutely controlled with intraarterial infusion of vasopressin, making an emergency colectomy unnecessary. Similarly in patients bleeding from inflammatory bowel disease or in patients with post-operative hemorrhage, angiography provides information about the nature of the lesion and selective arterial infusions of vasopressin can control the bleeding. At times intestinal varices have angiographically been demonstrated as a potential source of rectal hemorrhage while in patients with unexplained lower gastrointestinal bleeding and repeatedly negative barium and endoscopic examinations, angiography has been valuable for the diagnosis of angiodysplasia of the colon.