Dieulafoy's lesion is a relatively rare clinicopathological entity, considered as calibre persistent artery and it's a rare vascular malformation which can cause potentially life-threatening bleeding(1, 9).Its presentation depends on its location, ranging from haematemesis or melena to haematochezia. The most common and classic location for this lesion is fundus area of stomach, usually at 5 to 6 cm from the gastroesophageal junction along the lesser curvature(3). They can be found at any gastrointestinal location, including the esophagus, small intestine, colon, or rectum. Most of the haemorrhage is intermittent and severe, with haemodynamic instability present in almost 80% of the cases2-5.
The artery is histologically normal. However, it consists of an aberrant submucosa artery that erodes the overlying mucosa and cause severe gastrointestinal bleeding without an evidence of primary ulcer, erosion or aneurysm, maintaining a diameter of 1 to 3 mm (a calibre 10 times larger than a normal mucous capillary).
This lesion is thought to be the cause of only 1–5% in all gastrointestinal bleeding cases(1). Most of them are asymptomatic, posing a significant challenge as it is usually small, relatively inconspicuous and the lesion may cause bleeding only intermittently. To make matters worse, the lesion are usually visualized only during active bleeding(10).This leads to confusion with more common vascular diseases, such as arteriovenous malformations and hemangiomas (10).In addition, the focus may be covered by blood clots or active bleeding, making it more difficult to identify(11).
According to the literature, endoscopy is effective in diagnosing about 70% of the patients, and diagnostic accuracy increases with active bleeding(9).But in my opinion, in this case, a large amount of bleeding in the stomach causes excessive blood clots to form in the stomach, which leads to the coverage of blood clot and the disturbance of gastric emptying. Therefore, active bleeding does not mean that diagnostic accuracy can be improved. Gastroscopy should be performed as early as possible, rather than waiting until significant active bleeding is found. Gastrointestinal endoscopy is the first line diagnostic procedure since it allows for diagnosis and a possible therapeutic approach during active bleeding(4, 5). Besides, we also need to accurately grasp the diagnostic criteria for Dieulafoy's disease: (1) active arterial spurting or micropulsatile bleeding from small (< 3 mm) mucosal defects surrounded by normal mucosa; (2) the presence of protruding vessels; (3) fresh, adherent clots with a small point of attachment to the mucosal defect or to normal mucosa(11).
It frequently involves the male patient population at the fifth decade of life without any familial predisposition.4The patients with pre-existing comorbidities like diabetes, hypertension, cardiovascular disease, chronic kidney disease and alcoholism are at a higher risk for massive bleeding(9, 12).Despite the exact pathophysiology of a Dieulafoy’s lesion is unknown, two main hypotheses have been put forward. The first is that of a congenital base predisposing to the appearance of an abnormally dilated artery with risk of protrusion, rupture, and haemorrhage. The second hypothesis is based on a background caused by oxidative and ischemic stress, such as previous surgeries, chronic gastritis, and alcohol consumption or non-steroidal anti-inflammatory drug usage(8, 12, 13).
According to the two hypotheses recorded in the literature, congenital basilar artery abnormalities exist in this patient's gastric submucosa which we reported. Not only the trauma of operation but also the tension and anxiety of perioperative patient, will aggravate oxidative and ischemic stress. Under the action of multiple factors, the pulsatility of caliber-persistent submucosal arteries with histological normality leads the mucous membrane wall to thinning. Besides, the applications of glucocorticoid and NSAIDs cause a mucosal atrophy and an ischaemic injury. Over time, artery gets exposed to the contents of the stomach. Owing to the abnormal exposure of this vessel, even minor mechanical trauma from food bolus can lead to erosion of this artery causing severe acute gastrointestinal haemorrhage(14).
The final yield of diagnostic upper endoscopy is 70% for the Dieulafoy’s lesion while the initial diagnostic value is low. Only 49% of Dieulafoy’s lesions were identified during the initial endoscopic examination, 33% of patients required a second examination and 18% required exploratory laparotomy for accurate diagnosis(1).For the case we reported, in the third gastroscopy, we found the bleeding lesion and successfully stopped bleeding. Another important factor for the successful hemostasis of the patient we treated under endoscopy is that we tried to change the patient's position many times during the third gastroscopy examination, so as to reduce the influence of blood clot covering the bleeding site. When the patient was in prone position, we finally found jet bleeding on the gastric body near the great curvature of gastric fundus under gastroscope, and then we performed successfully with haemostatic clip placement.
Traditionally, surgical resection procedures like proximal gastric resection or wedge resection were considered as the treatments for gastric Dieulafoy’s lesions before 1990(15).However, recently endoscopic therapeutic procedures have replaced surgery to a large extent .This approach has been shown to be effective towards bleeding from a Dieulafoy's lesion with a success rate of over 90% (4, 9). When endoscopy fails to find the bleeding source, angiography may be helpful in locating and controlling it, with selective arterial embolization. This approach should be used in endoscopic failure, lesions not accessible by endoscopy and patients unsuitable for surgery(7, 15). Surgical treatment is necessary in less than 5% of cases, being reserved only when endoscopic or angiographic treatments fail(16).
The present case of Dieulafoy's lesion in the gaster secondary to the resection of lung cancer was diagnosed through gastroscopy, performed after patient's stabilization, with effective haemostasis after use of placement of haemostatic clips. The risk of bleeding recurrence varies between 9% and 40%. Repeated endoscopy is the therapy of choice in the evidence of recurrence(8). As for the present case, treatment was effective without recurrence.