Elsevier

Clinical Radiology

Volume 70, Issue 6, June 2015, Pages 661-666
Clinical Radiology

Pictorial Review
Dieulafoy lesion: CT diagnosis of this lesser-known cause of gastrointestinal bleeding

https://doi.org/10.1016/j.crad.2015.02.005Get rights and content

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. Due to its insidious onset, tendency to cause intermittent but severe bleeding, and difficulty of endoscopic diagnosis, Dieulafoy lesion has a very high mortality rate. Although originally thought not to be a radiologically diagnosable entity, Dieulafoy lesions can be seen at enhanced CT of the abdomen. The purpose of this review is to summarize the pathophysiology, epidemiology, diagnosis, and management of Dieulafoy lesions with a focus on diagnostic findings at enhanced CT imaging.

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

References (22)

  • N.P. Rossi et al.

    Massive bleeding of the upper gastrointestinal tract due to Dieulafoy’s erosion

    Arch Surg

    (1968)
  • Cited by (0)

    View full text