Dieulafoy lesion

An abnormally large gastric or duodenal submucosal artery at risk of causing erosion and bleeding

Epidemiology

• Accounts for 0.3-7% of non-variceal UGIB

Risk factors

• Occurs more commonly in med
• IHD
• CKD
• Diabetes

Pathophysiology

• Erosion of the superficial mucosa overlying the artery occurs secondary to pulsations of the large vessel
• Once exposed to gastric contents, bleeding occurs
• The mucosal defect is generally 2-5mm and surrounded by normal-appearing gastric mucosa, so can be hard to identify
• Generally occurs within 6cm of GOJ on the lesser curvature, but can also occur in duodenum

Presentation

• Classically - sudden-onset massive painless haematemesis
• Most patients present with haematemesis

Investigation

• Generally found on endoscopy for UGIB
• Intermittent bleeding - multiple endoscopies may be necessary

Management

• First-line - endoscopy
  • Dual therapy - coagulation and haemoclip
  • Can also do sclerotherapy or banding too
  • Successful 80-100%
• Second-line - repeat endoscopy
• Third-line - transcatheter embolisation
  • Most commonly left gastric artery
  • Reasonably successful
• Last-line - surgery
  • Gastric wedge resection
  • Best done as a dual procedure with scope down to transilluminate resection margin
  • Easier if it has been tattooed
  • Could also underrun the vessel through a gastrotomy