Rare case of upper gastrointestinal bleeding: Dieulafoy’ s l
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Dieulafoy's lesion (DL) (exulceratio simplex, cirsoid aneurysm or caliber-persistent submucosal vessel) is an unusual but important and potentially life threatening cause of gastrointestinal bleeding responsible for up to 5% of acute upper gastrointestinal bleeds. The ulcer is localized typically within 6–10 cm from the gastroduodenal junction. Frequently they find themselves on the small curvature and in the gastric body (67%), less on the bottom (25%). The endoscopical appearance and its management have been discussed in this report. This work has been reported in line with the SCARE criteria.

A 73-year-old male, hospitalized, with a history of chronic obstruction pulmonary disease, hypertension, and end-stage renal disease, presents in week before intermittent episodes of melena. He arrived at emergency room with hypotension, severe pallor and tachycardia, and an important hematemesis. His laboratory exams were: hemoglobin 5.5 g/dL, Hematocrit 22%. After resuscitation therapy with fluid, plasma and blood infusion, he underwent an esophagogastroduodenoscopy (EGDS) that revealed an important actively bleeding in the duodenal bulb. After rinsing and aspiration, it is identified the source of bleeding, which was a pulsatile lesion of a few millimeters which emerged the mucosa, with no signs of local inflammation, or peptic lesions like. Surgeons performed an epinephrine injection and electrocautery, but the bleeding was not controlled. Therefore, they used the hemoclips, but the important bleeding did not permit the control of hemostasis. Due to hemodynamic instability, it was not indicated to perform transarterial embolization.

Therefore, the patient was taken to the operating room and emergency laparotomy was performed (D.G.). After mobilization of pancreatoduodenal block, we performed a longitudinal duodenotomy, we found in the duodenal bulb, large pulsatile arteriole, that rises of mucosal, and it opened in the intestinal lumen. The rest the mucosa of the duodenum was normal explored. The characteristics of the lesion were suggestive of duodenal ulcer of Dieulafoy (Fig. 1). Hemostasis was controlled with vessel ligation, and a resection was not necessary. They are needed other infusions of blood after surgery 48 h after surgery, hemoglobin was 10.2, hematocrit was 29%. He patient had no bleeding late, or complications in the postoperative period. He was discharged 8 days after surgery.

It has been demonstrated that this injury is caused by an abnormality of anatomical arteriole under the mucosa, which appears dilated and tortuous. It starts very close to the surface of the basal membrane of the mucosa. The chronic trauma of arteriole pulse generates mucosal erosions and vessel rupture in the gastrointestinal lumen

Learning points:-
1. Dieulafoy's lesion is an uncommon but important cause of recurrent upper gastrointestinal bleeding.
2. Endoscopic vision shows actively bleeding, typically from point source on GI mucosa.
3. The localization of Dieulafoy's lesion in the duodenum or in the small intestine can be more difficult.
4. Endoscopic treatment is the first choice, often effective, repeatable, but related to a percentage of failure of 10%.
5. Surgical management is indicated when the lesion fails to respond to therapeutic endoscopy

Source: https://www.sciencedirect.com/science/article/pii/S2049080119300925
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