LETTERS TO THE EDITOR

 

Massive upper gastrointestinal bleeding due to a Dieulafoy's lesion inside a duodenal diverticulum

Hemorragia digestiva alta masiva secundaria a lesión de Dieulafoy oculta en un divertículo duodenal

 

 

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Key words: Dieulafoy. Bleeding. Diverticulum.

Palabras clave: Dieulafoy. Hemorragia. Divertículo.

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Dear Editor,

In relation to the article published in this journal by Valdivielso Cortázar et al. (1), we have recently diagnosed a massive digestive hemorrhage secondary to a Dieulafoy's lesion inside a duodenal diverticulum. This was successfully treated with endoscopy.

 

Case report

A 91-year-old male with anticoagulated atrial fibrillation with acenocoumarol attended the Emergency Room. The patient presented with hematemesis and rectal bleeding with a hemoglobin decrease of 5 gr/dl and associated hemodynamic instability. An urgent gastroscopy identified a non-ulcerated vascular lesion suggestive of a Dieulafoy's lesion inside a diverticulum in the second duodenal portion, with an active and oozing bleeding (Fig. 1). The lesion was sclerosed with adrenaline and aethoxysklerol and three endoclips were placed; eventually hemostasis was achieved (Fig. 1). The patient did not present with a new bleeding episode.

 

 

Discussion

Dieulafoy's lesions account for 5% of cases of acute upper gastrointestinal (GI) bleeding and is also an important cause of obscure gastrointestinal hemorrhage. It is a rare and often undiagnosed entity. The Dieulafoy's lesion is more frequent in elderly men with cardio-respiratory co-morbidities. It is usually located in the stomach and it is less frequently found in the duodenum (15%). It usually begins as a massive upper gastrointestinal bleed. Endoscopy is considered to be the gold standard for the diagnosis of Dieulafoy lesions but it can be difficult to visualize during an initial endoscopy due to its small size and the massive hemorrhage caused. Our patient presented a Dieulafoy's lesion inside a duodenal diverticulum, thus the treatment was even more difficult. Therapeutic endoscopy remains the first line of treatment option for controlling the bleeding while angiography and surgery are considered as valuable alternatives. The mortality rate due to a Dieulafoy's lesion has decreased from 80% to 8.6% in recent years due to endoscopic advances (2).

 

Lucía Relea-Pérez, Marta Magaz-Martínez and Fernando Pons-Renedo
Department of Gastroenterology. Hospital Puerta de Hierro Majadahonda.
Majadahonda. Madrid, Spain

 

References

1. Valdivielso Cortázar E, Madarnás Alonso L, Ortiz Martín S, et al. Hemorragia diverticular duodenal, un reto endoscópico. Rev Esp Enferm Dig 2017;109(6):468-9. DOI: 10.17235/reed.2017.4755/2016.         [ Links ]

2. Jeon HK, Kim GH. Endoscopic management of Dieulafoy's lesion. Clin Endosc 2015;48(2):112-20. DOI: 10.5946/ce.2015.48.2.112.         [ Links ]