Images in… BMJ Case Reports: first published as 10.1136/bcr-2017-223615 on 15 March 2018. Downloaded from Gastric Dieulafoy lesion: a rare cause of massive haematemesis in an elderly woman Jamie Clements,1 Barry Clements,2 Maurice Loughrey3 1General Surgery, Craigavon DESCRIPTION brisk haemorrhage from the gastroduodenal artery Area Hospital, Portadown, UK A 78-year-old woman presented to her local acci- (a branch of the hepatic artery). This diagnosis may 2 Department of General Surgery, dent and emergency department by ambulance, have been corroborated by the history of NSAID Royal Victoria Hospital, Belfast, having collapsed following several episodes of use; however, failure of endoscopy and angiog- UK voluminous fresh haematemesis with melaena. 3Department of Pathology, Royal raphy to identify a source of bleeding is typical of a Victoria Hospital, Belfast, UK The patient had extensive medical comorbidi- more occult source. ties, suffering from type 2 diabetes mellitus, isch- The diagnosis is that of a Dieulafoy lesion Correspondence to aemic heart disease, bronchiectasis and severe or ‘persistent calibre artery’ of the stomach. A Dr. Jamie Clements, pulmonary hypertension. Three weeks previously histomicrograph of the lesion is shown in figure 2, jclements06@ qub. ac. uk she had undergone an uncomplicated total hip depicting classical features of normal surface gastric replacement for osteoarthritis and had been using BC and ML contributed equally. mucosa, aside from a haemorrhagic ulcer (arrow) non-steroidal anti-inflammatory drugs (NSAIDs) penetrating a thick-walled arterial structure located for analgesia. She had no history of gastroenter- Accepted 1 March 2018 within the superficial submucosa, representing the ological disease. source of bleeding. The patient responded to initial resuscitative Dieulafoy lesion is a rare but well-recognised measures sufficiently to undergo oesophagogas- cause of UGIB. Lesions are most commonly troduodenoscopy. The gastroenterologist strug- located in the proximal stomach but have been gled to achieve any useful view of either stomach reported throughout the gastrointestinal tract.1 or duodenum due to the volume of haemorrhage, Bleeding may be self-limiting and intermittent, or and aborted the procedure. The patient rapidly severe, the latter necessitating urgent intervention. displayed signs of haemodynamic instability and Endoscopic detection is the diagnostic modality deteriorated into a state of refractory hypovo- of choice, although endoscopic identification of laemic shock. She was intubated and ventilated. The patient underwent laparotomy and the bleeding source may be extremely difficult, as antrotomy with duodenotomy, which showed no bleeding is typically intermittent and surrounding focal gastric or duodenal abnormality. Attempted mucosa is typically normal or demonstrates only a 2 http://casereports.bmj.com/ preservation of the gastric fundus did not arrest tiny ulcer. the arterial haemorrhage and control was only In the acute setting, profuse bleeding may achieved through total gastrectomy and oesophago- obscure the endoscopic view. CT angiography jejunostomy. The gastric specimen is displayed, may be a diagnostic strategy in the setting of acute with bleeding source highlighted by arrow and bleeding, which may facilitate interventional inset (figure 1). radiology and arterial embolisation. Definitive The list of differential diagnoses in this clinical situation is extensive (table 1). The most common cause of upper gastrointestinal bleeds (UGIBs) in this population is peptic ulceration, particularly on 27 September 2021 by guest. Protected copyright. posterior-wall duodenal ulcers, which can generate To cite: Clements J, Clements B, Loughrey M. BMJ Case Rep Published Online First: [please include Day Month Year]. doi:10.1136/ Figure 1 The resected gastric specimen demonstrating Figure 2 A histomicrograph of the same Dieulafoy bcr-2017-223615 the Dieulafoy lesion. lesion. Clements J, et al. BMJ Case Rep 2018. doi:10.1136/bcr-2017-223615 1 Images in… BMJ Case Reports: first published as 10.1136/bcr-2017-223615 on 15 March 2018. Downloaded from Table 1 Differential diagnoses of upper gastrointestinal bleeding Microscopic features Macroscopic features Clinical features Dieulafoy lesion Normal surface gastric mucosa aside from defect Mucosal erosion ~1–5 mm; 75% within 6 cm of <1% of UGIBs Histologically normal, tortuous submucosal the GOJ Intermittent painless melaena and haematemesis artery with an abnormally large arterial diameter Attached thrombus may be seen M:F 2:1 (1–3 mm) Absence of inflammation at the edge of the Small mucosal defect varying from 2 to 5 mm, mucosal defect with a fibrinoid necrotic base Duodenal ulcer Mucosal ulceration that can penetrate into Mucosal defect ~2–4 cm ~50% of UGIBs submucosa and muscularis propria, or perforate Diffuse, erythematous mucosal borders Symptoms: epigastric abdominal pain, belching, onto the serosal surface; degree of surrounding Bleeding vessel or adherent clot sometimes anorexia, haematemesis fibrosis relative to chronicity visible in ulcer base Risk factors: H. pylori infection, smoking, NSAIDs, Gastric ulcer Background mucosal changes depend on Mucosal defect ~2–4 cm steroids, vagal tone (Cushing’s ulcer), burns aetiology, for example, Helicobacter pylori Smooth base with perpendicular borders (Curling’s ulcer), Zollinger-Ellinson syndrome gastritis or NSAID-related reactive gastropathy Bleeding vessel or adherent clot sometimes (rare) (see below); most other causes, for example, visible in ulcer base peptic, have non-specific microscopic features Oesophageal varices Large dilated submucosal veins Dilated submucosal vessels in ‘columns’ 5%–10% of UGIBs Expanded submucosa with elevation of mucosa Commonly in distal oesophagus Haemorrhage risk: above normal tissue Small (1–2 mm) or large (1–2 cm) Size of varices ±Haemosiderin-laden macrophages Anticoagulants ±Fresh blood Active alcohol use Systemic infection Volume resuscitation can precipitate further haemorrhage—aim for stability and Hb >80 g/L Gastritis Microscopy depends on aetiology, for example, H. Mucosal erythema and oedema, typically 10%–20% of UGIBs pylori gastritis (usually antral but may be pan- associated with friability and superficial mucosal Heterogeneous phenomenon; the Sydney system gastric; bacteria highlighted by histochemistry); ‘breaks’ (erosions) or the Operative Link for Gastritis Assessment NSAID-related reactive gastropathy (foveolar staging system may be useful in diagnostics/ hyperplasia, fibromuscular lamina propria prognostics. expansion, paucity of inflammation); acute Common aetiology: H. pylori colonisation, gastritis (mucosal oedema, haemorrhage and NSAIDs, alcohol, critical illness superficial erosions) Treatment should comprise H. pylori eradication, antacid therapy and cytoprotective agents. Mallory-Weiss tear Longitudinal mucosal lacerations of the distal Longitudinal mucosal lacerations with or without Up to 10% of UGIBs oesophagus/proximal stomach, with surrounding active bleeding and adherent clot More common in the young haemorrhage and acute inflammatory reaction Occasionally healing tears may appear as Predisposing factors include alcoholism and superficial ‘blood blisters’ hiatus hernia Haematemesis initiated by severe coughing or retching http://casereports.bmj.com/ Non-bleeding tears may be managed conservatively, with acid suppression and antiemetics. GOJ, gastro-oesophageal junction; Hb, haemoglobin; NSAID, non-steroidal anti-inflammatory drug; UGIBs, upper gastrointestinal bleeds. management of catastrophic bleeding may require subtotal or and information from the respective consultants. ML: cosenior author; consultant total gastrectomy, and fatal cases are recognised.3 pathologist; interpreted pathological specimens for submission and described a short The patient recovered well in the initial postoperative period vignette on the pathological appearances of Dieulafoy lesions for submission. BC: cosenior author; the consultant surgeon who performed the gastric resection and but succumbed some months later from refractory pulmonary interpreted/prepared the surgical images for submission, in addition to supplying a hypertension. short clinical vignette. on 27 September 2021 by guest. Protected copyright. Funding The authors have not declared a specific grant for this research from any Contributors JC: corresponding author and primary author; organised funding agency in the public, commercial or not-for-profit sectors. correspondence between all parties and prepared the final draft for submission; led the concept and design of the article and assimilated the various clinical images Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. Learning points © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted. ► Dieulafoy lesions are an extremely rare but potentially fatal cause of upper and lower gastrointestinal bleeding, and should be included in the list of differential diagnoses for REFERENCES 1 Veldhuyzen van Zanten SJ, Bartelsman JF, Schipper ME, et al. Recurrent massive gastrointestinal haemorrhage. haematemesis from Dieulafoy vascular malformations--a review of 101 cases. Gut ► Diagnosis and treatment can be treacherous, given the occult 1986;27:213–22. and intermittent nature of the presentation of the Dieulafoy 2 Chen