Grand round presentation on Dieulafoy's lesions
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A 78-year-old man presented with syncope and was found to have gastrointestinal bleeding from a Dieulafoy's lesion. He underwent endoscopic clipping of the lesion, but rebled requiring a partial gastrectomy. Dieulafoy's lesions are an uncommon but potentially life-threatening cause of gastrointestinal bleeding, characterized by abnormally large tortuous arteries in the stomach wall. They typically present with hematemesis or melena and are diagnosed and treated endoscopically when possible, but may require angiography, embolization, or surgery for refractory bleeding.
Grand round presentation on Dieulafoy's lesions
- 1. Grand Round Case Presentation on Dieulafoy's lesions Dr. Nadia Gulnaz General/ GI surgery Team of Prof. MC Anena
- 2. Initial presentation • 78 years old gentleman presented to A&E • Single episode of syncope attack and fall • B/G: • Left CEA 10 days earlier • Right CEA in 2013 • IHD (stents in 2005) • HTN • COPD Ex. smoker • THR in 2014
- 4. On arriaval • GCS 15/15 • Haemodynamicaly stable • BP 147/74 • HR 80 • RR 18 • Temp 36.4
- 5. Physical examination • Pallor + • 2cm laceration + bruising around left eye • Right sided facial droop • Neck (CEA) wound clean without any signs of infection • Power intact bilaterally.
- 6. Initial management • Wide bore IV line • Bloods sent (FBC, U/E, Coagulation Profile) • Group and cross match • CT scan of brain organised • Patient was catheterized • IV fluids
- 7. Investigations findings • WBC 10.4 • Hb 9.6 • Plat 230 • CRP 3.3 • Urea 7.5 • Creat. 61 • Coag. profile normal • Ct scan Brain…..no pathology found
- 8. Where should the patient go?
- 9. Vascular team input • Vascular team was called to review the patient. • Initial impression: • ? Postural hypotension • ? TIA/ CVA – Patient was admitted – Arranged Carotid duplex – And Holter monitor
- 10. 1st day of admission • Carotid duplex…..both sides patent with good flow • Telemetry…..no positive findings
- 11. 2nd day of admission • Ophathalmology review: – No eye/sight damage • Stroke team review for the RT sided facial droop: – Droop; Not due to neurological deficit
- 13. 3rd day of admission • Cardiology opinion: – Telemetry un remarkable – Episode of syncope….postural – Stable Coronary artery disease – Stable from cardiac point of view
- 14. Should we send him home ???
- 15. 3rd day of admission • Patient developed melena • Became cold , clammy and pale++ • In distress but No abdominal pain • B.P 90/40 • HR 97 • RR 24 • O2 saturation 91 on room air • Temp 36
- 16. Investigations • Hb 5.2 • WBC 22.4 • Plts 211 • CRP 1.5 • Urea 14.4 • Creat. 67 • Coag. profile normal
- 17. What is the source of bleeding?
- 19. • On call General Surgical team contacted; – Antiplatelets stopped
- 20. General surgical team input • On examination: – Dark blood in rectum….. – No P/R mass or piles, normal anal tone • Impression: – Likely upper GI bleed
- 21. General surgical team input • Patient kept NPO • 2 x Wide bore IV lines • I/V fluids started • PPI 80 mg stat then 8mg/hr • Urgent crossmatch RCC and transfusion started • Emergency OGD organized.
- 22. OGD Findings
- 23. OGD Findings
- 24. OGD Findings • Clots of fresh blood in stomach and distal oesophagus • A visible spurting vessel in fundus • Likely DIEULAFOY’S lesion • Lesion injected with 1:10000 adrenaline and clipped • Achieved satisfactory haemostasis. • Patient shifted to HDU • Received 4 RCC and 2x platelets.
- 25. OGD Intervention
- 26. OGD Intervention
- 27. OGD Intervention
- 28. Day 1 post OGD in HDU • GCS 15/15 • HR 80 • BP 109/55 • RR 16 • Hb 9.6 • Plat 211 • Pt 11.9 APTT 19.5 • O2 saturation 98% on room air • Patient stable and shifted to ward
- 29. Day 2 post OGD • Patient collapsed in ward • Cardiac arrest team was called but he was found to be oriented in TPP • Hb found to be 4.8 on ABGs • A new large episode of melena was reported by staff
- 30. Other parameters • HR 108 • BP 162/58 • RR 14 • Temp 38.8 • 02 saturation 100% on mask • Hb 4.8 • Plat 142 • Pt 12.2 • APTT 21.4 • INR 1.0
- 32. Management • Resuscitation started • Patient shifted to theater for emergency OGD • Findings: • Stomach full of clots • Suction with wide orogastric tube • Active bleeding from same mucosal vessel in fundus • Endoscopic control not possible !!
- 33. OGD Findings
- 34. Patient underwent lap. partial gastrectomy
- 35. Post Operative Course • Patient shifted to ICU --- intubated • Extubated next day • Haemodynamically stable. • Stable haemoglobin (6.2) • Next day shifted to HDU • Post operative recovery unremarkable • Received 4x RCC 2X Plasma and 2x Platelets perioperatively. • Sent home 4th post op. day with stable HB of 11.41 g/dl
- 37. Dieulafoy's lesions • Dieulafoy's lesion is a relatively rare, but potentially life-threatening, condition. It accounts for 1–2% of acute gastrointestinal (GI) bleeding
- 38. Dieulafoy's lesions • Characterized by a large tortuous arterioles in the stomach wall (sub mucosal) that erodes and bleeds. • Named after French surgeon Paul Georges Dieulafoy, who described this condition in his paper in 1898 • Also called "caliber-persistent artery" or "aneurysm" of gastric vessels
- 39. Dieulafoy's lesions • Approximately 75% occur in the upper part of the stomach within 6 cm of the gastroesophageal junction, most commonly in the fundus and lesser curvature. • Extragastric lesions are relatively uncommon • In contrast to peptic ulcer disease, a history of alcohol abuse or NSAID use is usually absent
- 40. Presenting Symptoms • Recurrent hematemesis with melena • Hematemesis without melena • Melena with no hematemesis
- 41. Diagnosis • A Dieulafoy's lesion is difficult to diagnose, because of the intermittent pattern of bleeding. • Usually vessels can be localized Endoscopically • Angiography or endoscopic u/sound is a good additional diagnostic tool.
- 42. Treatment • Endoscopic techniques used in the treatment: –Epinephrine followed by coagulation, –injection sclerotherapy, –heater probe, –laserphotocoagulation, –haemoclipping or banding.
- 43. Treatment • In Patients with refractory bleeding Interventional Radiology may be consulted for an angiogram with selective embolization • Surgical excision can be used in emergency setting
- 44. Prognosis • The mortality rate for Dieulafoy's was much higher before the era of endoscopy, where open surgery was the only treatment option
- 46. Take home message • Always think of hemodynamic stability and ABC • Common things are common but don’t forget the uncommon • Be Careful not to kill the patient and know when to call for somebody’s help • 10-15% patients presenting with acute severe hematochezia/melena have Upper GI source • If surgery is required, pre-operative localization is crucial. • With localization, recurrent bleeding seen in < 4% pts