Nisan 2014

18-20

Şehmus ÖLMEZ ¹ , Bünyamin SARITAŞ ², Mehmet ASLAN ³ , Ahmet Cumhur DÜLGER ¹, İbrahim AYDIN ³

Departments of ¹ Gastroenterology, and ³ Internal Medicine, Yüzüncü Yıl University Medical Faculty, Van ² Department of Gastroenterology, Muş Public Hospital, Muş

Dieulafoy lezyonu nadir görülen ancak önemli bir üst gastrointestinal kanama nedenidir. Sıklıkla midede görülmekle birlikte ince ve kalın bağırsaklarda da görülebilir. Tipik olarak gastroözofageal bileşkeden sonraki 6 cm içinde, küçük kurvatur yönünde yerleşir. Bu lezyonlara bağlı kanamada, hemostazı sağlamak için değişik endoskopik yöntemler kullanılır ve kanayan Dieulafoy lezyonu tedavisi için en uygun endoskopik tedavi yöntemi henüz iyi tanımlanmamıştır. Argon plazma koagülasyonu üst gastrointestinal kanamada başarılı bir şekilde kullanılmasına rağmen Dieulafoy lezyonuna bağlı kanamalarda kullanımı sınırlıdır. Burada enjeksiyon tedavisi ve argon plazma koagülasyonu ile kombine olarak tedavi edilen, kanayan gastrik Dieulafoy lezyonu olan olguyu sunacağız.

Dieulafoy lezyonu, gastrointestinal kanama, argon plazma koagülasyonu, tedavi

Dieulafoy’s lesion (DL) is a caliber−persistent submucosal artery associated with a minute mucosal defect (1). DL is a rare cause of gastrointestinal bleeding, which can be life- threatening or recurrent if left untreated, and it has an incidence of 0.3–6.7% (2). Endoscopic treatment has replaced surgery as Şehmus ÖLMEZ 1 , Bünyamin SARITAŞ 2, Mehmet ASLAN 3 , Ahmet Cumhur DÜLGER 1, İbrahim AYDIN 3 the standard diagnostic and therapeutic method for bleeding DLs (3). Endoscopic interventions, such as band ligation, thermocoagulation with heater probe, bipolar electrocoagulation, photocoagulation, injection therapy, and endoscopic hemoclip application, are among the first choices in the therapy (1,2). The control of bleeding due to DLs can usually be provided with endoscopic therapy, but the best modality of endoscopic intervention is not yet certain (1,2). Epinephrine monotherapy has a higher rate of rebleeding (4). Argon plasma coagulation (APC) is compact, mobile and easy-to–use, and has a relatively low cost when compared with the other treatment modalities (5). APC has been used successfully in the upper gastrointestinal tract. However, experience using APC to treat DLs is quite limited (3,6). We report a case of a 58-year-old female who admitted to the emergency department with hematemesis and melena. During endoscopy, a non-bleeding vessel was seen on the lesser curvature of the stomach near the gastroesophageal junction, and a diagnosis of DL was made. The lesion was managed with APC and injection sclerotherapy.

Dieulafoy’s lesion (DL) is an important cause of upper gastrointestinal bleeding, and this lesion may be seen anywhere Combined treatment of Dieulafoy’s lesion: Case report throughout the gastrointestinal tract, but it usually develops in the proximal stomach, predominantly on the lesser curvature (1,9). DLs are usually found within 6 cm of the gastroesophageal junction; the arterial flow in this area emerges directly from the left gastric artery (4). DLs are usually associated with comorbidity such as cardiovascular disease, arterial hypertension or renal failure (4,7).) The most frequent clinical manifestation of DLs is a massive upper digestive hemorrhage. It is probably a recurrent bleeding without pain, and is associated with a severe life-threatening hemodynamic condition, affecting previously healthy individuals without gastrointestinal diseases or peptic symptoms (3,4). Advances in endoscopy have increased the detection rate of DLs and significantly decreased the mortality (3,7). The endoscopic criteria proposed to define DLs are: active arterial spurting or micropulsatile streaming from a minute (<3 mm) mucosal defect or through normal surrounding mucosa; visualization of a protruding vessel with or without active bleeding within a minute mucosal defect or through surrounding normal mucosa; and fresh, densely adherent clot with a narrow point of attachment to a minute mucosal defect or to normal appearing mucosa (7). The first step to diagnosis DLs is endoscopy, but due to the small size of the lesion, its relatively inaccessible localization and the presence of blood and blood clots, the diagnosis is difficult (3,7). Success rates for the first endoscopy range from 77-92,4% (1,8). Therefore, repeated endoscopy may be necessary (3,7). Endosonography and angiography can also be used for the diagnosis of DLs (4,7). Several treatment methods like endoscopy, surgery and angiography with embolization have been described for DLs (7). Embolization treatment may lead to ischemia. Surgical treatment may only be necessary in 5% of DLs. Today, endoscopic treatment is the first treatment choice. The safety and efficacy of endoscopic treatments have been widely accepted (1,2,7). Endoscopic interventions in DLs have a success rate of 75– 100% in controlling the hemostasis using variable treatment methods, such as injection therapy, heater probe, endoscopic hemoclip placement (EHP), and endoscopic band ligation (EBL) (1,2,9), and the mortality rates have decreased from 80% to 8.6% (7). Nevertheless, there is still no consensus with regard to the optimal method of treatment (1,2,7). Epinephrine injection is the most commonly used method due to its availability, low cost and safety. Hemostasis in DLs can be controlled with epinephrine injection alone, but the risk of rebleeding is high, and it requires surgery rather than other endoscopic methods (4,9). Mechanical hemostasis causes less damage to the surrounding tissue than injection or thermal therapy, and several reports have shown the superiority of the mechanical endoscopic methods (EHP or EBL) over injection or thermal treatment. Both EHP and EBL have shown good results for initial hemostasis and long-term outcome. Both are simple methods and easy to perform. The advantage of EHP is its lack of side effects, and therefore, it is a preferred therapy option for DLs (1,9); however, it is very hard to perform when the lesion is tangential or visible only in the retroflexed position of the endoscopy (2,6). On the other hand, APC is a noncontact electrocoagulation method that is used especially for chronic radiation proctitis, watermelon stomach and ablation of Barrett’s esophagus. Further, APC can be used in bleeding due to peptic ulcers, angiodysplasia and DLs (6). This method may be advantageous over the contact thermal methods since it permits targeting of the bleeding sites, even if tangential, and reduces the risk of perforation by limiting the depth of the tissue damage (6). APC can be performed easily to lesions through frontal and lateral probes, independently, depending on the location (2,6,10). A combined endoscopic approach with injection of epinephrine and APC can be used to treat DLs (6,11). In conclusion, if DLs are not recognized and treated properly, they may cause upper gastrointestinal bleeding, which is lifethreatening. Especially in technically difficult cases and in the centers equipped with an APC unit, it may be suitable to use APC together with injection sclerotherapy for the treatment of DLs.

Dieulafoy’s lesion (DL) is an important cause of upper gastrointestinal bleeding, and this lesion may be seen anywhere Combined treatment of Dieulafoy’s lesion: Case report throughout the gastrointestinal tract, but it usually develops in the proximal stomach, predominantly on the lesser curvature (1,9). DLs are usually found within 6 cm of the gastroesophageal junction; the arterial flow in this area emerges directly from the left gastric artery (4). DLs are usually associated with comorbidity such as cardiovascular disease, arterial hypertension or renal failure (4,7).) The most frequent clinical manifestation of DLs is a massive upper digestive hemorrhage. It is probably a recurrent bleeding without pain, and is associated with a severe life-threatening hemodynamic condition, affecting previously healthy individuals without gastrointestinal diseases or peptic symptoms (3,4). Advances in endoscopy have increased the detection rate of DLs and significantly decreased the mortality (3,7). The endoscopic criteria proposed to define DLs are: active arterial spurting or micropulsatile streaming from a minute (<3 mm) mucosal defect or through normal surrounding mucosa; visualization of a protruding vessel with or without active bleeding within a minute mucosal defect or through surrounding normal mucosa; and fresh, densely adherent clot with a narrow point of attachment to a minute mucosal defect or to normal appearing mucosa (7). The first step to diagnosis DLs is endoscopy, but due to the small size of the lesion, its relatively inaccessible localization and the presence of blood and blood clots, the diagnosis is difficult (3,7). Success rates for the first endoscopy range from 77-92,4% (1,8). Therefore, repeated endoscopy may be necessary (3,7). Endosonography and angiography can also be used for the diagnosis of DLs (4,7). Several treatment methods like endoscopy, surgery and angiography with embolization have been described for DLs (7). Embolization treatment may lead to ischemia. Surgical treatment may only be necessary in 5% of DLs. Today, endoscopic treatment is the first treatment choice. The safety and efficacy of endoscopic treatments have been widely accepted (1,2,7). Endoscopic interventions in DLs have a success rate of 75– 100% in controlling the hemostasis using variable treatment methods, such as injection therapy, heater probe, endoscopic hemoclip placement (EHP), and endoscopic band ligation (EBL) (1,2,9), and the mortality rates have decreased from 80% to 8.6% (7). Nevertheless, there is still no consensus with regard to the optimal method of treatment (1,2,7). Epinephrine injection is the most commonly used method due to its availability, low cost and safety. Hemostasis in DLs can be controlled with epinephrine injection alone, but the risk of rebleeding is high, and it requires surgery rather than other endoscopic methods (4,9). Mechanical hemostasis causes less damage to the surrounding tissue than injection or thermal therapy, and several reports have shown the superiority of the mechanical endoscopic methods (EHP or EBL) over injection or thermal treatment. Both EHP and EBL have shown good results for initial hemostasis and long-term outcome. Both are simple methods and easy to perform. The advantage of EHP is its lack of side effects, and therefore, it is a preferred therapy option for DLs (1,9); however, it is very hard to perform when the lesion is tangential or visible only in the retroflexed position of the endoscopy (2,6). On the other hand, APC is a noncontact electrocoagulation method that is used especially for chronic radiation proctitis, watermelon stomach and ablation of Barrett’s esophagus. Further, APC can be used in bleeding due to peptic ulcers, angiodysplasia and DLs (6). This method may be advantageous over the contact thermal methods since it permits targeting of the bleeding sites, even if tangential, and reduces the risk of perforation by limiting the depth of the tissue damage (6). APC can be performed easily to lesions through frontal and lateral probes, independently, depending on the location (2,6,10). A combined endoscopic approach with injection of epinephrine and APC can be used to treat DLs (6,11). In conclusion, if DLs are not recognized and treated properly, they may cause upper gastrointestinal bleeding, which is lifethreatening. Especially in technically difficult cases and in the centers equipped with an APC unit, it may be suitable to use APC together with injection sclerotherapy for the treatment of DLs.

1. Sone Y, Kumada T, Toyoda H, et al. Endoscopic management and follow up of Dieulafoy lesion in the upper gastrointestinal tract. Endoscopy 2005; 37: 449-53. 2. Ahn DW, Lee SH, Park YS, et al. Hemostatic efficacy and clinical outcome of endoscopic treatment of Dieulafoy’s lesions: comparison of endoscopic hemoclip placement and endoscopic band ligation. Gastrointest Endosc 2012; 75: 32-8. 3. Linhares MM, Filho BH, Schraibman V, et al. Dieulafoy lesion: endoscopic and surgical management. Surg Laparosc Endosc Percutan Tech 2006; 16: 1-3. 4. Jamanca-Poma Y, Velasco-Guardado A, Piñero-Pérez C, et al. Prognostic factors for recurrence of gastrointestinal bleeding due to Dieulafoy’s lesion. World J Gastroenterol 2012; 40: 5734-8. 5. Manner H, May A, Faerber M, Rabenstein T, Ell C. Safety and efficacy of a new high power argon plasma coagulation system (hp-APC) in lesions of the upper gastrointestinal tract. Dig Liver Dis 2006; 38: 471-8. 6. Iacopini F, Petruzziello L, Marchese M, et al. Hemostasis of Dieulafoy’s lesions by argon plasma coagulation. Gastrointest Endosc 2007; 66: 20-6. 7. Baxter M, Aly EH. Dieulafoy’s lesion: current trends in diagnosis and management. Ann R Coll Surg Engl 2010; 92: 548-54. 8. Yarze JC. Routine endoscopic “marking” of Dieulafoy like lesions. Am J Gastroenterol 2001; 96: 264-5. 9. Lara LF, Sreenarasimhaiah J, Tang SJ, Afonso BB, Rockey DC. Dieulafoy lesions of the GI tract: localization and therapeutic outcomes. Dig Dis Sci 2010; 55: 3436-41. 10. Yarze JC. Argon plasma coagulation of Dieulafoy’s lesions. Gastrointest Endosc 2006; 63: 733. 11. Souza JLS. Treatment of Dieulafoy’s lesion of the right colon with epinephrine injection and argon plasma coagulation. Endoscopy 2009; 41: E192.