By Asif M. Qadri, MD
A 55 year old male with otherwise very limited medical problems is enjoying Father’s Day with his kids and grandkids. He is a world traveler and enjoys the finer things in life including great food and wine. He is not overweight and exercises daily. After enjoying brunch with his family, they settle by the pool and enjoy the day. The man suddenly feels nauseated and excuses himself to the bathroom. While getting up, he nearly trips as he was a little unsteady on his feet. Ten minutes later, his son finds him in the bathroom passed out with blood all over the floor. He is rushed to the hospital with low blood pressure and still vomiting blood albeit feeling better after receiving fluids and anti-nausea medication. The ER physician quickly diagnoses a brisk upper GI Bleed and immediately starts resuscitation measures with more fluids, blood products and labs. Of course he is quickly on the phone with his favorite gastrointestinal physician who needs to see the patient ASAP. After clinically assessing the patient and labs, an upper endoscopy is performed that reveals a blood filled stomach.
After carefully examining the duodenum (initial segment of the small bowel), the endoscope is slowly withdrawn. Upon entering back into the stomach, the view of the stomach is obscured by pulsatile blood which begins to slowly fill up the stomach with even more blood. You quickly locate the source.
Calmly, the physician requests a Resolution Clip or two which he applies to stop the bleeding.
Whew! The patient ultimately spends a few days in the hospital but is alive and well when discharged home. What was that??? That, my friend, was a Dieulafoy lesion.
A Dieulafoy lesion is a condition whereby a large and usually tortuous artery like vessel erodes through the layers of the stomach and spontaneously bleeds. It is rare and makes up less than 5% of all gastrointestinal bleeding in adults therefore making this a life threatening event. It is named after Paul Georges Dieulafoy, a French surgeon, who described the condition in 1898. The stomach is the most common site for a Dieulafoy lesion accounting for more than 75% of reported cases. The mucosal defect occurs most commonly on the lesser curve with 80% to 95% of these lesions being located within 6 cm of the gastroesophageal junction.
Because of the relative intermittent bleeding pattern and difficulty to recognize this aberrant vessel, it is often missed. However, persistent endoscopy allows detection especially when active bleeding is witnessed in the form of vomiting blood or passing blood or black stools rapidly. Women rejoice as this is twice more commonly found in men. While the exact pathogenesis is not well understood, the general consensus is that there is some form of mucosal erosion or ischemic injury that is possibly related to aging or cardiovascular disease which further weakens this vulnerable area and unmasks the silent anomaly. Endoscopically, hemostasis can be achieved by procedures and can be classified into three groups: (i) thermal – electrocoagulation, heater probe coagulation and argon plasma coagulation; (ii) regional injection – local epinephrine injection and sclerotherapy; and (iii) mechanical – banding or the use of a hemostatic clip.
Prior to the advent of endoscopy, only surgery was curative but mortality from this lesion was about 89%. Now endoscopy alone will positively treat around 90% of patients while the remaining 10% may have to undergo an interventional radiology procedure called angiography to stop the bleeding. With that being said, please be aware of your overall health and let us at Athens Digestive Healthcare Associates assist in your digestive care by specializing in your personal care for both Gastroenterology and Hepatology.
Dr. Qadri attended the School of Medicine at American University of the Caribbean. He is Board Certified in Internal Medicine and specializes in Gastroenterology, Hepatology, and Internal Medicine. He is part of Athens Digestive Healthcare Associates: 1500 Oglethorpe Ave # 500. Athens, GA 30606. For more information and to schedule an appointment, please call (706) 850-4985.