Overview
Definition:
A Dieulafoy lesion is a common cause of acute, severe, and often recurrent upper gastrointestinal bleeding, characterized by an abnormally large submucosal artery that erodes through the mucosa
Surgical oversew involves direct suture ligation of the bleeding vessel and surrounding tissue to achieve hemostasis when endoscopic or other minimally invasive methods fail or are not feasible.
Epidemiology:
Dieulafoy lesions account for approximately 2-5% of all cases of severe upper gastrointestinal bleeding
They are most frequently found in the proximal stomach, typically within 6 cm of the gastroesophageal junction along the lesser curvature
Incidence increases with age, and they are more common in patients with comorbidities like cardiovascular disease, renal failure, and those on anticoagulant or antiplatelet therapy
Male predominance is noted.
Clinical Significance:
Dieulafoy lesions are clinically significant due to their potential for massive and life-threatening hemorrhage, often with minimal prodromal symptoms
Prompt and definitive management is crucial to prevent exsanguination, shock, and associated mortality
Understanding the surgical approach is vital for residents preparing for DNB and NEET SS examinations, as it represents a challenging scenario requiring precise surgical technique.
Clinical Presentation
Symptoms:
Hematemesis, often bright red or coffee-ground
Melena or hematochezia if bleeding is brisk
Epigastric pain, though often absent
Syncope or dizziness due to hypovolemia
Signs of shock: hypotension, tachycardia, pallor, cool extremities.
Signs:
Pallor of conjunctivae and mucous membranes
Tachycardia
Hypotension
Abdominal examination may be unremarkable, or mild epigastric tenderness may be present
Signs of hypovolemic shock if bleeding is severe.
Diagnostic Criteria:
Diagnosis is typically made endoscopically
Criteria include visualization of a pulsating or actively bleeding artery protruding through an otherwise intact or minimally eroded mucosa, usually in the proximal stomach
Absence of a discrete ulcer or other obvious source of bleeding is characteristic
Definitive diagnosis often requires exclusion of other causes of upper GI bleeding.
Diagnostic Approach
History Taking:
Detailed history of bleeding episodes: frequency, volume, color of vomitus/stool
Recent use of NSAIDs, aspirin, or anticoagulants
Presence of comorbidities like hypertension, renal insufficiency, or cardiovascular disease
Prior history of GI bleeds or interventions
Significant medical history and medications.
Physical Examination:
Assessment for hemodynamic stability: vital signs (BP, HR, RR, O2 saturation)
Assess for pallor, peripheral perfusion, and signs of hypovolemic shock
Abdominal palpation for tenderness or masses
Rectal examination to assess for melena.
Investigations:
Complete Blood Count (CBC) to assess hemoglobin and hematocrit levels, and platelet count
Coagulation profile (PT/INR, aPTT) to assess hemostasis
Liver function tests (LFTs) and renal function tests (RFTs)
Endoscopy (EGD) is the gold standard for diagnosis, allowing direct visualization and often therapeutic intervention
Angiography may be used if endoscopy is non-diagnostic or if active bleeding is suspected but not seen endoscopically, guiding selective embolization
CT angiography can also be useful.
Differential Diagnosis:
Peptic ulcer disease (gastric or duodenal)
Esophagitis or gastritis
Mallory-Weiss tear
Gastric varices
Gastric malignancy
Dieulafoy lesion is often a diagnosis of exclusion when other causes are ruled out and an aberrant vessel is identified.
Management
Initial Management:
Immediate resuscitation with intravenous fluids (crystalloids, colloids) to maintain hemodynamic stability
Blood transfusion as necessary based on hemoglobin levels and clinical status
Correction of coagulopathy if present
Placement of a nasogastric tube for gastric lavage and decompression.
Medical Management:
Proton pump inhibitors (PPIs) are crucial in high-dose intravenous regimens (e.g., pantoprazole 80 mg bolus followed by 40 mg/hr infusion) to reduce gastric acid secretion and promote healing, although they do not directly stop arterial bleeding
Octreotide may be considered in some bleeding scenarios but is not the primary treatment for Dieulafoy lesions.
Surgical Management:
Surgical oversew is indicated when endoscopic hemostasis fails, is not achievable, or if the lesion is inaccessible endoscopically
The goal is to directly ligate the aberrant vessel
Options include: 1
Open laparotomy with gastrotomy and direct suture ligation of the bleeding vessel and surrounding submucosa using non-absorbable sutures (e.g., 3-0 or 4-0 Prolene)
Careful identification of the vessel is paramount
2
Laparoscopic approach for oversew, which offers less morbidity but requires significant laparoscopic skill
Excision of the involved segment may be considered if the lesion is extensive or difficult to ligate reliably.
Supportive Care:
Continuous hemodynamic monitoring (BP, HR, CVP if available)
Serial CBC monitoring to assess for ongoing blood loss
Strict NPO initially, followed by gradual reintroduction of oral intake as tolerated
Nutritional support may be required for patients with prolonged NPO status
Close monitoring for recurrence of bleeding.
Complications
Early Complications:
Rebleeding (most common) after initial treatment
Hemorrhagic shock
Injury to adjacent structures during surgery (e.g., esophagus, pancreas)
Gastric perforation
Anastomotic leak if gastric resection is performed.
Late Complications:
Stricture formation at the site of oversew or repair
Recurrence of bleeding from the same or a new lesion
Adhesions leading to bowel obstruction
Gastric stasis.
Prevention Strategies:
Meticulous surgical technique during oversew to ensure secure ligation of the aberrant vessel and surrounding tissue
Adequate preoperative resuscitation and stabilization
Judicious use of PPIs postoperatively
Careful consideration of antiplatelet/anticoagulant therapy, balancing risk of bleeding with thrombotic risk.
Prognosis
Factors Affecting Prognosis:
Hemodynamic stability at presentation
Degree of blood loss and comorbidities
Success of initial hemostasis (endoscopic or surgical)
Promptness of definitive treatment
Age and overall health status of the patient.
Outcomes:
With successful endoscopic or surgical management, the prognosis is generally good, with low recurrence rates
However, Dieulafoy lesions are known for their potential to rebleed, with recurrence rates ranging from 5-30%
Mortality is primarily related to the severity of bleeding and associated comorbidities, rather than the lesion itself if treated effectively.
Follow Up:
Patients require close follow-up after treatment
Endoscopic surveillance may be considered in high-risk patients or those with recurrent bleeding
Continued medical management with PPIs is often recommended
Patients should be advised on lifestyle modifications and avoidance of aggravating factors like NSAIDs.
Key Points
Exam Focus:
Dieulafoy lesions are characterized by an aberrant, tortuous submucosal artery eroding through the mucosa, typically along the gastric lesser curvature
They cause sudden, massive, and recurrent upper GI bleeding
Surgical oversew involves direct suture ligation of the vessel and surrounding tissue
Location, vessel identification, and secure ligation are critical surgical principles.
Clinical Pearls:
When encountering massive upper GI bleeding with a negative or equivocal initial endoscopy, always consider a Dieulafoy lesion, particularly in the proximal stomach
Angiography can be both diagnostic and therapeutic (embolization)
Surgical oversew requires meticulous identification of the aberrant vessel to prevent recurrence
Consider the patient's comorbidities and need for anticoagulation carefully when planning management.
Common Mistakes:
Failing to consider Dieulafoy lesion in cases of obscure GI bleeding or massive hematemesis
Inadequate surgical exposure or failure to identify the specific bleeding vessel during oversew
Over-reliance on PPIs without definitive hemostasis
Aggressive cautery or clipping which might damage the vessel wall without securing it, leading to rebleeding.