Management of Dieulafoy Lesion

Definition and Epidemiology

Dieulafoy lesion is a tortuous submucosal artery in the GI tract that penetrates through the mucosa over time, causing gastrointestinal bleeding, as described by the American College of Radiology 1

Aggressive volume resuscitation and maintenance of hemodynamic stability are the first priorities before attempting to identify and treat the source of hemorrhage, according to the American College of Radiology and Praxis Medical Insights 1, 2
For patients with significant bleeding, placement of two large-bore IV catheters and infusion of normal saline to stabilize vital signs is recommended by Praxis Medical Insights 2
Transfusion of blood is indicated when bleeding is severe or when hemoglobin is less than 100 g/L in acute bleeding, as suggested by Praxis Medical Insights 2

Upper endoscopy should be performed as the first diagnostic study after resuscitation, as recommended by the American College of Radiology and the American College of Physicians, based on evidence from Annals of Internal Medicine 1, 3
In hemodynamically unstable patients with suspected active bleeding, CT angiography could be considered as a first-line study, according to Radiology 4
Dieulafoy lesion can be difficult to diagnose and may require repeated endoscopy if initial examination is negative, as noted by Gut 5
Multiphase CT enterography can help detect Dieulafoy lesions, which are most conspicuous on arterial phase imaging, as described by Radiology 4

Hemoclips are particularly useful for actively bleeding large vessels and have similar efficacy to band ligation, as reported by Gut 5
Epinephrine injection can achieve initial hemostasis but has higher rebleeding rates when used alone, according to Gut 5
Combination therapy, such as injection plus thermal methods, may be more effective than injection alone for active arterial bleeding, as suggested by Gut 5

Endoscopic mechanical therapy with either band ligation or hemoclipping is the first-line treatment, with hemoclipping particularly useful for actively bleeding vessels, as recommended by Gut 5

High-dose proton pump inhibitor therapy is recommended after successful endoscopic therapy, as suggested by Gut 5
Close monitoring of vital signs, including continuous observation of pulse, blood pressure, and urine output, is recommended by Praxis Medical Insights 2
Patients who are hemodynamically stable 4-6 hours after endoscopy can begin oral intake, according to Praxis Medical Insights 2

For Dieulafoy lesions in the small intestine beyond the reach of standard endoscopy, deep enteroscopy or intraoperative enteroscopy may be required, as described by Gastroenterology 6, 7
In patients with recurrent bleeding from Dieulafoy lesions, consideration of underlying coagulopathies or use of anticoagulant medications is recommended by Praxis Medical Insights 2