Pictorial ReviewDieulafoy lesion: CT diagnosis of this lesser-known cause of gastrointestinal bleeding
Introduction
A Dieulafoy lesion describes a tortuous, submucosal artery in the gastrointestinal tract—most commonly the posterior stomach—that penetrates through the mucosa over time, eventually perforating to cause severe gastrointestinal bleeding.1, 2, 3 The lesion is not associated with surrounding ulcer or inflammation. Due to its insidious onset, tendency to cause intermittent but severe bleeding, and difficulty of diagnosis, a Dieulafoy lesion has up to an 80% mortality rate.4 Due to intermittent and heavy bleeding, initial endoscopic evaluation often does not provide accurate diagnosis of Dieulafoy lesions. Enhanced imaging, especially CT angiography (CTA), can help fill the diagnostic gap by locating the bleeding vessel.
Section snippets
History
Dieulafoy lesion was first identified in 1884 by M.T. Gallard, a French surgeon who described three cases of apparent gastric ulcerations responsible for fatal massive bleeding. In 1898, the lesion was described in more detail and named “Exulceratio simplex” by Paul Georges Dieulafoy (Fig 1), another French surgeon. He described and illustrated the lesion and its histology (Fig 2), as well as its common location in the upper stomach. He also mentioned that the lesion was so small and
Pathophysiology
Whereas a normal artery of the GI tract narrows progressively as it courses distally along the wall of the end organ, the artery that composes a Dieulafoy lesion maintains its calibre without narrowing. Fig 3 shows an example of such a lesion at CT as an abnormally prominent submucosal arteriole within the stomach of a patient with gastrointestinal bleeding. This artery is histologically normal and usually maintains a width of between 1 and 3 mm, even distally.1, 2 The artery also runs a more
Epidemiology and clinical presentation
Although Dieulafoy lesions are commonly thought to be quite rare, accounting for only 1–2% of acute gastrointestinal bleeding,1, 12 their apparent rarity is at least in part related to under-diagnosis. A Dieulafoy lesion is usually asymptomatic until presentation with an often massive bleed. Furthermore, its diagnosis is difficult as the lesion is most commonly quite small and endoscopically elusive. The lesion may be covered with clot or be obscured by active bleeding. During periods when the
Diagnosis
Dieulafoy lesions present a particular diagnostic challenge for several reasons. Firstly, as they are rare they can often be mistaken for other lesions such as arteriovenous malformations, aneurysms, or even Mallory–Weiss tears.17, 18 Furthermore, the lesions can be quite small, indiscriminate, and bleed only intermittently. Also, as the majority of cases present with massive bleeding, endoscopic detection can sometimes be difficult. Pooling of blood in the fundus of the stomach or a large clot
CT findings of dieulafoy lesion
Diagnosis with CT has henceforth been significantly rarer than angiography. Only a single prior case report showed diagnosis with contrast-enhanced CTA of the abdomen. The CT examination showed a tortuous vessel in the proper distribution with active extravasation of contrast material into the stomach lumen.22 The CT findings of a Dieulafoy lesion include an abnormally enlarged submucosal vessel, which may appear serpentine, linear, or as a non-specific blush of apparent mucosal/submucosal
Conclusion
Near-definitive diagnosis of a Dieulafoy lesion can be obtained with enhanced CT of the abdomen. Optimal studies are performed in the arterial phase of intravenous contrast enhancement without administration of oral contrast material. CTA shows an enlarged submucosal arteriole in the gastrointestinal submucosal layer with or without active contrast medium extravasation into the lumen. Familiarity with the lesion and its manifestations can help guide radiologists to make the correct diagnosis in
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Cited by (21)
Jejunum vascular lesion with gastrointestinal haemorrhage: focus on CT imaging and endovascular treatment
2022, Visual Journal of Emergency MedicineCitation Excerpt :Dieulafoy lesions are uncommon, but they can cause life-threatening bleeding. A Dieulafoy lesion is a tortuous submucosal artery in the gastrointestinal tract that gradually penetrates the mucosa before perforating and causing significant gastrointestinal bleeding 4. Dieulafoy lesions and arteriovenous malformations are detected on digital subtraction angiography by the presence of arterial nidus.
Dieulafoy's lesion in the cecum: A rare case report presentation
2021, International Journal of Surgery Case ReportsCitation Excerpt :Studies demonstrated a higher success rate with mechanical haemostatic techniques than with local haemostatic injections alone [2,4,15]. In addition, the combined use of different endoscopic techniques showed a lower rate of haemorrhagic recurrence compared with endoscopic monotherapy [4,9,16]. In most cases, haemostasis is achieved through local injection of epinephrine in conjunction with heat probe coagulation or haemostatic clip placement [4,17,18].
Recurrent gastrointestinal bleeding secondary to Dieulafoy's lesion successfully treated with endoscopic ultrasound-guided sclerosis
2018, Gastroenterologia y HepatologiaACR Appropriateness Criteria<sup>®</sup> Nonvariceal Upper Gastrointestinal Bleeding
2017, Journal of the American College of RadiologyCitation Excerpt :Missed diagnoses in studies correlating CTA to angiography and/or surgery have included gastric ulcers and vascular malformations [99]. CTA can show Dieulafoy lesions that are associated with a very high mortality rate [100]. CTA protocol design is critical to diagnostic efficacy for identification of GI hemorrhage.
Obscure Upper Gastrointestinal Bleeding in the Presence of Jaundice and Abdominal Pain
2015, GastroenterologyBleeding from Dieulafoy's lesion: a case report on a nonagenarian man and a review of the literature
2020, Revista Espanola de Geriatria y Gerontologia