GI Endoscopy · 1 min read
Endoscopic Management of a Duodenal Dieulafoy's Lesion
A spurting D2 Dieulafoy in a 37-year-old woman, closed with one through-the-scope clip.
Experienced teaching points
Clinical Pearls
- A Dieulafoy's lesion is a dilated, tortuous arteriole that erodes through a small mucosal defect. There is usually no ulcer around it.
- When the vessel is visible and spurting, a single well-placed clip can stop the bleed immediately.
- Mechanical compression is a first-line option here. Injection or thermal therapy can wait if the clip already closed the vessel.
- These lesions bleed hard and can be missed. If the first look is dry, go back during the next bleed.
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| Patient: | 37-year-old woman with chronic kidney disease and diabetes |
| Indication: | One day of hematochezia with diaphoresis and hypertension |
| Final diagnosis: | Duodenal Dieulafoy's lesion with acute gastrointestinal bleeding, treated with a single endoscopic clip |
Clinical History
A 37-year-old woman with chronic kidney disease and diabetes presented with one day of hematochezia. She was diaphoretic and hypertensive. Emergency endoscopy was performed for acute gastrointestinal bleeding.
Endoscopic Findings
- A spurting bleeding point in the second portion of the duodenum.
- A protruding vessel without surrounding ulceration, the typical Dieulafoy's pattern.
Endoscopic Technique
One hemostatic clip was placed on the spurting vessel in D2. Hemostasis was immediate. No further therapy was needed, and there were no complications.
Discussion
A Dieulafoy's lesion is an abnormally large submucosal arteriole that erodes through a pinpoint mucosal defect. The surrounding mucosa is usually intact. That is why the bleed can look like nothing until the vessel jets, and why it can recur if the first exam is done between bleeds.
Panel A is the emergency: active spurting in D2. Panel B is the diagnostic still: a nipple-like vessel with no ulcer crater. Panel C is the treatment: one through-the-scope clip, vessel closed, field dry.
Injection and thermal therapy still have a role in GI bleeding. For a visible, spurting Dieulafoy, a clip gives mechanical occlusion you can see. Place it while the vessel is in view.
References
- Veldhuyzen van Zanten SJO, Bartelsman JF, Schipper ME, Tytgat GN. Endoscopic sclerosis of a Dieulafoy's lesion. Endoscopy. 1986;18(5):211-213.
- Lee HY, Lim PN, Tham DK, et al. Endoscopic treatment of Dieulafoy lesions. Clin Endosc. 2011;44(4):279-281.
- Loffeld RJLF. Dieulafoy's lesion: endoscopic diagnosis and treatment. Dig Liver Dis. 2011;43(2):103-105.
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