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      The Diagnostic Dilemma of Dieulafoy’s Lesion

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          Abstract

          Dieulafoy’s lesion (DL) is a relatively rare condition which carries a significantly high risk for mortality. A tortuous large arteriole in the wall of the stomach can result in significant gastrointestinal (GI) hemorrhage which can result in detrimental complications. Although it only accounts for about 1% of all GI bleeding, it has been considered to be one of the most underrecognized conditions. This train of thought may unfortunately be related to the difficulty in its diagnosis. After conducting a Medline search of the medical literature, with a focus on current PubMed articles, a thorough examination of updated diagnostic and treatment approaches was compared. Diagnostic techniques in the analysis and treatment of DLs continue to be limited to this day. Endoscopy remains as the main diagnostic and therapeutic tool; however, it continues to have its limitations. Other alternatives include but are not limited to angiography and surgical interventions which at times can be more successful. Diagnostic improvements and research for the detection of DL continue to advance; however, they remain limited in their capabilities. Further analysis and workup needs to be conducted in order to reduce hospital stay and improve survival.

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          Most cited references39

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          Dieulafoy's lesion.

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            Bleeding Dieulafoy's lesions and the choice of endoscopic method: comparing the hemostatic efficacy of mechanical and injection methods.

            Dieulafoy's lesion has unique endoscopic and histopathologic characteristics. This is a clinical trial of endoscopic therapy in 24 patients with Dieulafoy's lesions. Patients were divided into 2 groups according to initial endoscopic treatment method. Data were analyzed with respect to clinical and endoscopic characteristics as well as outcomes. The 24 patients were evenly divided into mechanical (9 hemoclipping, 3 band ligation) and injection groups (12). The average number of therapeutic endoscopic sessions needed to achieve permanent hemostasis for the mechanical and injection groups were 1.17 and 1.67, respectively. Initial hemostasis was achieved in 91.7% of patients undergoing mechanical therapy and 75% of those undergoing injection therapy, with none in the former group needing subsequent surgery in comparison to 17% of the latter group. The rate of recurrent bleeding in the mechanical therapy group was significantly lower in comparison to the injection therapy group (8.3% versus 33.3%, p < 0. 05). Higher efficacy in terms of initial hemostasis and less recurrent bleeding was achieved by mechanical hemostatic therapy with hemoclip and band ligation compared with injection therapy. Endoscopic mechanical therapy is recommended as effective for bleeding Dieulafoy's lesions.
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              Gastrointestinal bleeding from Dieulafoy's lesion: Clinical presentation, endoscopic findings, and endoscopic therapy.

              Although relatively uncommon, Dieulafoy's lesion is an important cause of acute gastrointestinal bleeding due to the frequent difficulty in its diagnosis; its tendency to cause severe, life-threatening, recurrent gastrointestinal bleeding; and its amenability to life-saving endoscopic therapy. Unlike normal vessels of the gastrointestinal tract which become progressively smaller in caliber peripherally, Dieulafoy's lesions maintain a large caliber despite their peripheral, submucosal, location within gastrointestinal wall. Dieulafoy's lesions typically present with severe, active, gastrointestinal bleeding, without prior symptoms; often cause hemodynamic instability and often require transfusion of multiple units of packed erythrocytes. About 75% of lesions are located in the stomach, with a marked proclivity of lesions within 6 cm of the gastroesophageal junction along the gastric lesser curve, but lesions can also occur in the duodenum and esophagus. Lesions in the jejunoileum or colorectum have been increasingly reported. Endoscopy is the first diagnostic test, but has only a 70% diagnostic yield because the lesions are frequently small and inconspicuous. Lesions typically appear at endoscopy as pigmented protuberances from exposed vessel stumps, with minimal surrounding erosion and no ulceration (visible vessel sans ulcer). Endoscopic therapy, including clips, sclerotherapy, argon plasma coagulation, thermocoagulation, or electrocoagulation, is the recommended initial therapy, with primary hemostasis achieved in nearly 90% of cases. Dual endoscopic therapy of epinephrine injection followed by ablative or mechanical therapy appears to be effective. Although banding is reportedly highly successful, it entails a small risk of gastrointestinal perforation from banding deep mural tissue. Therapeutic alternatives after failed endoscopic therapy include repeat endoscopic therapy, angiography, or surgical wedge resection. The mortality has declined from about 30% during the 1970's to 9%-13% currently with the advent of aggressive endoscopic therapy.
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                Author and article information

                Journal
                Gastroenterology Res
                Gastroenterology Res
                Elmer Press
                Gastroenterology Research
                Elmer Press
                1918-2805
                1918-2813
                August 2015
                22 July 2015
                : 8
                : 3-4
                : 201-206
                Affiliations
                [a ]Internal Medicine Department, Raritan Bay Medical Center, 530 New Brunswick Avenue, Perth Amboy, NJ 08861, USA
                [b ]Internal Medicine Department, Maimonides Medical Center, 4802 10th Ave, Brooklyn, NY 11219, USA
                [c ]Internal Medicine Department, Jersey City Medical Center, 355 Grand St, Jersey City, NJ 07302, USA
                [d ]St. George’s University School of Medicine, University Centre, Grenada, West Indies
                Author notes
                [e ]Corresponding Author: Rafay Khan, Internal Medicine Department, Raritan Bay Medical Center, 530 New Brunswick Avenue, Perth Amboy, NJ 08861, USA. Email: rafay.t.khan@ 123456gmail.com
                Article
                10.14740/gr671w
                5040527
                27785297
                66295d3a-5632-4ad4-8358-ebf1c588bed0
                Copyright 2015, Khan et al.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 15 July 2015
                Categories
                Review

                dieulafoy’s lesion,hemorrhage,gastrointestinal bleeding,endoscopy,diagnosis

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