Overview of Dieulafoy lesion
Dieulafoy’s disease, also known as constant diameter arteriovenous malformation, is a disease in which the branches of the blood-supplying arteries do not gradually thin to form capillaries, but instead maintain a constant diameter that reaches the gastric mucosa, resulting in damage to the gastric mucosa under the impact of high-pressure blood flow.
Etiology
During the development of the embryo, due to internal or external factors, the branches of the blood supply artery of the stomach (mainly originating from the left gastric artery) enter the gastric mucosa, but maintain a constant diameter instead of gradually thinning to form capillaries.
Symptoms
Patients with Dieulafoy lesions tend to have gastrointestinal bleeding as the first symptom. Alcohol consumption, smoking, non-steroidal anti-inflammatory drugs, bile reflux, eating rough and hard food may lead to gastric mucous membrane damage, which may cause rupture and bleeding of the aberrant artery, etc. Dieulafoy’s disease also has its own characteristic clinical manifestations: ① age of onset: most common in middle-aged and old-aged males, the incidence of males is about twice as high as that of females. (2) Sudden onset without aura, and life-threatening hemorrhage can occur. There is no history of long-term, periodic abdominal pain, cirrhosis of the liver, gastrointestinal tumor disease and ulcer disease. ④ The condition is easy to be repeated: after rupture and bleeding of small arteries of constant diameter, blood crusts can be formed, bleeding stops temporarily, and bleeding can be repeated when the blood crusts fall off or the arteries are damaged.
Examination
1. Endoscopy is preferred for patients with clinically suspicious Dieulafoy lesions. Endoscopic characteristics are: ① site and peptic ulcer common site is not consistent: the typical site is 6cm below the cardia, the incidence of proximal gastric site is about 65%, the gastric sinus is relatively rare. ② small mucosal defects: isolated mucosal defects, mostly within 2-5mm in diameter. ③There is no obvious inflammation around the mucosa of the defect, and a prominent blood vessel break can be seen in the center. ④ There may be blood crust, blood seepage or visible pulsatile bleeding on the exposed vessels.
2. Selective abdominal arteriography also has some diagnostic value for this disease. The imaging features include increased, twisted, clustered, ring-shaped or bulbous dilatation of the terminal arteries; often accompanied by early venous reflux; no aneurysm formation or arteriovenous shunt exists.
Diagnosis.
Patient history combined with endoscopy confirms the diagnosis in most patients with Dieulafoy lesions. Due to the low incidence of Dieulafoy lesions and the small size of the lesions, they are easily confused clinically with peptic ulcers. Therefore, Dieulafoy lesions should be excluded from the clinical diagnosis of peptic ulcer, especially in patients with acute hemorrhage, lesions located in the fundus or the body of the stomach, and ineffective treatment with proton pump inhibitors.
Treatment
There are three main modalities for the treatment of Dieulafoy lesions: endoscopy, intervention and surgery. Endoscopic treatment is safe and effective and is the treatment of choice for Dieulafoy lesions, which can be categorized into pharmacologic hemostasis and mechanical hemostasis. Intervention is mainly angiographic embolization. Surgical treatment includes major gastrectomy, local excision and simple suture.