What is Dieulafoys Lesion Causing Gastrointestinal Bleeding?
A Dieulafoy lesion is a rare, abnormally large blood vessel formed in the digestive system; a condition first identified by the French Surgeon, Paul Georges Dieulafoy, in 1898. It accounts for 1 to 2 percent of all gastrointestinal bleeding cases and 6.5 percent of non-variceal upper gastrointestinal bleeding cases, which can be life-threatening.
The Dieulafoy lesion, which is typically 1 to 3 mm wide, is a normal blood vessel that protrudes into the mucus layer from underneath, creating a small wall defect in the digestive tract. Additionally, there is tissue death at the base of the lesion. Most of these lesions, nearly about 70 pct., are found in the stomach, usually along the lesser curvature.
What Causes Dieulafoys Lesion Causing Gastrointestinal Bleeding?
A Dieulafoy lesion is a large blood vessel located beneath the surface of the stomach’s lining which can bleed even without the presence of abnormalities like ulcers. Most of these lesions can be found in a specific area of the stomach, close to where the stomach and esophagus connect. These lesions happen here because this area gets its blood supply straight from the left gastric artery’s branches.
Sometimes, these lesions can also appear in other parts of the digestive tract – like the duodenum, colon, or esophagus – and even the site of a surgical connection.
Bleeding from a Dieulafoy lesion often occurs in individuals with certain health conditions like cardiovascular disease, chronic kidney disease, high blood pressure, peptic ulcer disease, diabetes, and in those who frequently use certain medications, like nonsteroidal anti-inflammatory drugs (NSAIDs) and blood thinners.
Risk Factors and Frequency for Dieulafoys Lesion Causing Gastrointestinal Bleeding
Dieulafoy lesions cause 6.5% of upper digestive system bleeding. Of those who experience these lesions, men are twice as likely as women to get them. This pattern changes in youth, where they are equally common in boys and girls. People of all ages can get these lesions, but they’re most common in people in their fifties who have other health conditions, like heart disease, high blood pressure, chronic kidney disease, and diabetes.
- Dieulafoy lesions are the cause of 6.5% of upper digestive system bleeding.
- They are found twice as often in men as in women in the adult population.
- In children, the rate is equal among boys and girls.
- People of all ages can get Dieulafoy lesions, but they’re most common in those in their fifties.
- There is a higher incidence in those with health problems like heart disease, high blood pressure, kidney disease, and diabetes.
Signs and Symptoms of Dieulafoys Lesion Causing Gastrointestinal Bleeding
Dieulafoy lesions typically don’t show any symptoms unless the top layer of the vessel gets damaged, which can lead to bleeding. This bleeding can be mild or severe, depending on how much blood is lost. Some people might experience dark, tarry stools called melena, vomiting blood (hematemesis), or passing fresh or altered blood in the stool (hematochezia). Other symptoms can include a type of anemia caused by iron deficiency, coughing up blood (hemoptysis), or signs of low blood pressure due to the blood loss (hemodynamic instability). In rare cases, if the Dieulafoy lesion is in the gallbladder, there might be upper abdominal pain without any noticeable bleeding.
- Dark, tarry stools (Melena)
- Vomiting blood (Hematemesis)
- Passing fresh or altered blood in the stool (Hematochezia)
- Anemia caused by iron deficiency
- Coughing up blood (Hemoptysis)
- Signs of low blood pressure due to blood loss (Hemodynamic instability)
- In rare cases, upper abdominal pain without any noticeable bleeding
Testing for Dieulafoys Lesion Causing Gastrointestinal Bleeding
To diagnose Dieulafoy’s lesion, doctors usually use a technique called endoscopy, which allows them to visually examine inside the body, in this case, the digestive tract. This involves a flexible tube with a camera at the end. Usually, one endoscopy is enough to spot the lesion, but if things like food or blood are obstructing, more than one might be necessary. Here’s what doctors look for during endoscopy:
1. Normal tissue surrounding a small wounded tissue area that has small, active bleeding, less than 3mm in size.
2. A blood vessel sticking out from a little defect or from normal tissue.
3. A fresh blood clot attached to a wound on the normal tissue.
If the endoscopy doesn’t spot the lesions, other techniques can be used to confirm the diagnosis like angiography or capsule endoscopy. Angiography involves injecting a special dye into the bloodstream and then taking X-ray images to see the blood vessels. Capsule endoscopy allows visual inspection of the digestive tract by swallowing a tiny camera in a capsule. In an angiogram, signs of Dieulafoy’s lesion include the seepage of dye into the digestive tract from a damaged artery, and the presence of twisted blood vessels without early blood return to veins. Scanning using technetium-99m labeled red blood cells or CT angiography can also help visualize the source of the bleeding.
Treatment Options for Dieulafoys Lesion Causing Gastrointestinal Bleeding
The first and most common treatment for a Dieulafoy lesion, a rare but potentially life-threatening cause of gastrointestinal bleeding, is a procedure called endoscopy. Before the 1980s, this condition was often treated through surgical methods, involving removal or opening of part of the stomach. However, since 1986, endoscopic procedures have largely replaced these more invasive techniques.
There are three commonly used endoscopic treatments:
1. Thermal techniques, which involve the use of heat probes or a procedure called argon plasma coagulation.
2. Regional injections, using substances like epinephrine or norepinephrine.
3. Mechanical methods — applying a band or clip to the bleeding area.
Among these, mechanical treatments using bands or clips are considered the safest and most effective. One study found that a treatment called endoscopic band ligation (EBL) resulted in lower chances of bleeding again and a shorter hospital stay in comparison to other techniques. The use of clips, also known as hemoclipping, has also been successful in treating Dieulafoy lesions, with a success rate of 95%.
Combining these methods could potentially lead to better results than using just one treatment. To make it easier to identify the exact location of bleeding in future, the site is often marked, or “tattooed,” with India ink during the endoscopic procedure.
If these endoscopic treatments are unsuccessful, surgery may be the next step. This can include cutting away a large section of the lesion or a part of the stomach.
What else can Dieulafoys Lesion Causing Gastrointestinal Bleeding be?
A Dieulafoy lesion can sometimes be confused with other health conditions, especially because the patient’s age, other health issues, and overall health can play a part. One significant condition to rule out is angiodysplasia, mainly because it can show similar symptoms.
Usually, doctors can tell these two conditions apart by doing an angiography. This is a kind of test that looks at blood vessels. If there is abnormal blood vessel connection (arteriovenous shunting) and expansion (vascular ectasia), it could be angiodysplasia. A closer look at the tissue under a microscope can also help. If it shows abnormal blood vessels beneath the lining of the stomach or intestines, it’s likely to be angiodysplasia.
Other conditions that might seem similar to a Dieulafoy lesion at first include diverticulosis (small, bulging pouches in the digestive tract), vascular neoplasms (abnormal growths in blood vessels), mucosal spider nevi (small red or purple spider veins), and connective tissue disorders. Doctors rely on the symptoms that patients come in with, endoscopy (where a small camera is used to look inside the body), and again, angiography (looking at the blood vessels), to rule these out.
What to expect with Dieulafoys Lesion Causing Gastrointestinal Bleeding
The rate of death and complications from Dieulafoy lesions has significantly decreased to 8.6% because of advancements in endoscopy techniques. Endoscopy allows for successful control of bleeding in 80 to 85% of the cases.
Possible Complications When Diagnosed with Dieulafoys Lesion Causing Gastrointestinal Bleeding
This condition is often not detected early because its signs are very subtle. This can lead to late treatment and potential complications. The most common issue is heavy spontaneous bleeding in the digestive tract, which could be life-threatening if not addressed. Occasionally, the loss of blood may lead to a shortage of iron in the body, causing anemia, and in critical cases, unstable blood pressure and heart rates. Additionally, the condition could exacerbate pre-existing health problems.
Preventing Dieulafoys Lesion Causing Gastrointestinal Bleeding
People should reduce the chances of developing a Dieulafoy lesion by steering clear of nonsteroidal anti-inflammatory drugs (better known as NSAIDs) and alcohol. It’s also crucial to have ongoing regular appointments with a stomach and intestine specialist, or gastroenterologist. They can keep a check on the situation and help prevent the Dieulafoy lesion from coming back.
