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Dieula
The disease is one of the rare causes of severe gastrointestinal bleeding. The disease is characterized by hidden bleeding sites, arterial bleeding, rapid bleeding, large and repeated bleeding, often leading to shock and endangering the patient’s life.
With the improvement of the understanding of this disease and the advancement of endoscopy technology in recent years, the reports of this disease have gradually increased.
Dieulafoy disease in one sentence
Dieulafoy disease, also known as submucosal constant diameter artery rupture and bleeding, is one of the rare causes of severe gastrointestinal bleeding.
Classic clinical manifestations
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The typical presentation of Dieulafoy’s disease is – sudden, unwarranted, fatal gastrointestinal bleeding followed by hemorrhagic shock soon (most Dieulafoy disease patients with major bleeding are in hypovolemic shock at the time of presentation).
Once blood pressure has been restored by blood transfusion, it is easy to bleed again, and major bleeding can appear Periodically,bleeding can lead to death if not managed properly.
At-Risk Population “Portraits”
Dieulafoy disease can be seen in all age groups, but it is more common in middle-aged and elderly people, especially in the 40-60 years old. The average age of onset of Dieulafoy disease in my country was 63 years old, and the incidence was higher in males (male to female ratio was 6.6:1).
Risk Factors:
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➤Hypertension, coronary heart disease, cerebrovascular disease, diabetes mellitusThese are characterized by vascular disease Main features of associated disease;
➤ taking nonsteroidal Mucosal damage due to anti-inflammatory drugs or warfarin;
➤Old age and other physical and chemical factors.
How is Dieulafoy disease diagnosed?
1Preferred test: endoscopy
Gastric endoscopy is the preferred diagnostic method for this disease, and its diagnostic rate for active or recent bleeding lesions is high.
Endoscopic diagnostic criteria:
(1) Jet-like bleeding or oozing or fresh blood clots, bleeding from small superficial mucosal defects less than 3 mm, The surrounding mucosa is normal;
(2) Small superficial mucosal defect, no general ulcer depression, superficial Prominent blood vessels are seen, while the surrounding mucosa is normal, with or without active bleeding.
Notes:
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➤The gastric submucosal constant-diameter artery is mainly derived from the lesser curvature of the left gastric artery, and 80%ofThe bleeding focus was located at the back of the gastric body and the anterior wall near the lesser curvature of the stomach within 6 cm below the cardia; The second was the duodenum, and the third was the colon.
Therefore, special attention should be paid to focal mucosal erosions, defects or lesions in the center of the lesion within 6 cm below the cardia. Pulsatile bleeding, or a clot in the center of the lesion can be seen.
➤ During emergency gastroscopy, there is often a lot of blood in the gastric cavity, and the lesions are not clearly exposed, resulting in misdiagnosis .
Therefore, before gastroscopy, a thicker gastric tube can be placed, repeated with norepinephrine saline, or The blood in the stomach is sucked out, and the gas is properly inflated to flatten the folds and facilitate the detection of lesions (Figures 1-3).
Fig. 1 Dieulafoy disease on the fundus of stomach, bleeding has stopped.
Figure 2 Dieulafoy disease of gastric fundus, there is a little white coating on the surface of the lesion and fresh oozing blood around it.
Fig.3 Cardiavascular remnant and Dieulafoy disease on the fundus of the stomach. block.
2Gastrointestinal angiography
It also has certain effects on this disease diagnostic value, but it must be in active bleeding, and the bleeding rate is greater than 0.5 ml/min.
This test can detect signs of vascular malformations in addition to bleeding sites. Its accuracy rate is 20% to 30%.
After the bleeding site is found by angiography, it can also be embolized with a wire ring and gelatin sponge under the conditions of angiography Bleeding vessels are treated.
Treatment of Dieulafoy Disease
With the development of endoscopic treatment technology, endoscopic treatment has become the preferred treatment for Dieulafoy disease.
Endoscopic treatment methods include: spraying hemostatic drugs, local injection of epinephrine, sclerotherapy, physical and chemical therapy , bandage and titanium clips, etc. Recently, it has been reported that titanium clip has obvious hemostatic effect and little trauma.
However, endoscopic treatment has the possibility of rebleeding, with an incidence rate of 10%. Endoscopic treatment can be performed after rebleeding.
The disease has a 30-day mortality rate of 13%, mainly due to fatal hemorrhage.
Real case list
A 68-year-old male patient was recently diagnosed with alcoholic cirrhosis in an external hospital.
The patient presented with hematemesis, melena, with tachycardia, mild hypotension, and acute hemorrhagic anemia (hemoglobin 9 gm/dL, baseline value is 11.5 gm/dL).
After resuscitation, the patient underwent esophagogastroduodenoscopy (EGD), where doctors found large blood clots in the fundus and body of the stomach , no esophageal varices or duodenal lesions were found.
The patient was referred to this hospital for the management of possible fundal varices.
Re-examination of EGD showed a large, protruding blood vessel near the bottom of the stomach, no active bleeding, no ulcer at the base, consistent with gastric Dieulafoy lesions (Figure 4).
Figure 4
Considering that the exposure was likely to trigger rebleeding, the physician decided to administer OTSC to this patient (Fig. 5, see below).
Figure 5
2 days later the patient was successfully discharged, 3 At follow-up months later, the patient was in stable condition without recurrent bleeding.
Dieulafoy disease, have you learned it?
References:
[1]Memon J, Rustagi T, Gastric Dieulafoy’s Lesion, Clinical Gastroenterology
and Hepatology (2020), doi: https://doi.org/10.1016/j.cgh.2020.07.043.< /p>
[2] Huang Li, Yang Shuhong. Analysis of the causes of misdiagnosis of Dieulafoy disease [J]. Clinical Misdiagnosis and Mistreatment. 2007(6).
[3] Fan Kaichun.Dieulafoy disease[J].China Digestive Endoscopy.2007(4).
[4] Zhang Xiaojun, Wu Yun. Dieulafoy in shock 2 cases [J]. Asian Emergency Medicine Case Study. 2019(1):1-4.