Southern Medical Journal:
Special Sections: Letters to the Editor
Department of Internal Medicine, AtlantiCare Regional Medical Center, Atlantic City, NJ
To the Editor:
Dieulafoy lesion is an uncommon cause of major gastrointestinal bleeding and may be difficult to recognize. It consists of a large caliber artery that protrudes through a mucosal defect in the stomach causing significant and often recurrent hemorrhaging from a pinpoint nonulcerated arterial lesion. It has been identified more frequently in recent years due to increased awareness. Dieulafoy lesion is thought to be the cause of acute and chronic upper gastrointestinal bleeding in approximately 1–2% of these cases.1 The incidence, however, might vary from 0.5% to 14%, depending upon selection criteria.2 Because a history of nonsteroidal anti-inflammatory drug (NSAID) intake, peptic ulcer symptoms, or alcohol abuse is usually absent, the condition is difficult to recognize.
A 19-year-old woman with a nonsignificant past medical history who recently emigrated from Thailand presented to the hospital with dizziness, lightheadedness, headache, progressive dyspnea, bilateral leg swelling, and a fever for two days. She also had three episodes of coffee ground vomiting and melena on the day of admission. She was using acetaminophen and Thai herbal medications for dysmenorrhea. She was a nonsmoker, nondrinker, and denied any drug abuse. Her blood pressure was 101/50, pulse rate was 116, and temperature was 38°C. She was lethargic and dyspneic, and her skin and conjunctiva were pale. Lung examination was normal, but the cardiovascular exam revealed tachycardia. While the abdominal examination was unremarkable, she had tarry stools on rectal exam. Extremity examination revealed moderate bilateral ankle edema. Her blood test showed a hemoglobin of 2.8 g/dL, albumin of 2.8, and a total protein of 4.5. Her electrolytes and chemistry were within normal limits. She was admitted to the intensive care unit with a diagnosis of upper gastrointestinal bleeding and severe anemia. Treatment with intravenous fluids and packed red blood cells was started. Her symptoms improved markedly in a few days and she became afebrile. Her stay was complicated by a modest elevation in troponin with normal creatine phosphokinase. Echocardiography revealed a normal ejection fraction with no wall motion abnormalities. This was attributed to supply ischemia. Upper endoscopy revealed a normal esophagus and a Dieulafoy lesion in the fundus with a stigmata of recent bleeding. The lesion was coagulated with a bipolar probe. The antrum was hyperemic but there were no ulcers identified in the stomach or duodenum. A biopsy for Helicobacter pylori was negative. Colonoscopy was unremarkable. The patient remained symptom-free and was discharged from the hospital with proton pump inhibitor therapy.
Dieulafoy lesion should be considered when evaluating any acute and recurrent major gastrointestinal bleeding. If unrecognized, it may cause a life-threatening hemorrhage. Usually, the mean hemoglobin level on admission has been reported to be between 8.4–9.2 g/dL in various studies.1,3 Awareness of the condition is a key to accurate diagnosis. It can be easily overlooked at endoscopy as concomitant lesions such as ulcers or varices may wrongly be considered responsible for the bleeding episode. Treatment is by endoscopic modalities like electrocoagulation and successfully achieves permanent hemostasis in 85% of cases.4 This case illustrates a rare and inherently difficult lesion to recognize, because it presents with very low hemoglobin, which is usually uncommon in Dieulafoy lesion, and did not have any risk factor for gastrointestinal bleeding. In practice, we have to consider unusual causes of common diseases to decrease their mortality and morbidity.
Musa Njeru, MD
Ali Seifi, MD
Zia Salam, MD, FACE
Lawrence Ognibene, DO, FACOI
Department of Internal Medicine
AtlantiCare Regional Medical Center
Atlantic City, NJ
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3. Dy NM, Gostout CJ, Balm RK. Bleeding from the endoscopically-identified Dieulafoy lesion of the proximal small intestine and colon. Am J Gastroenterol 1995;90:108–111.
4. Ho KM. Use of Sengstaken-Blakemore tube to stop massive upper gastrointestinal bleeding from Dieulafoy’s lesion in the lower oesophagus. Anaesth Intensive care 2004;32:711–714.