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Q1: What is the diagnosis?
Dieulafoy’s lesion in the stomach. Recommended treatment is thermal ablation.
Dieulafoy’s lesion is an important cause of upper gastrointestinal haemorrhage and may account for up to 5% of acute haemorrhages.1 Dieulafoy et al described it in 1897 as exulceratio simplex, cirsoid aneurysm.1 The histological appearance is characteristic; a relatively large calibre artery that lies close to the mucosal surface, likely as a congenital anomaly. Most Dieulafoy lesions are diagnosed by their endoscopic features. The features are arterial bleeding or non-bleeding visible vessel stigmata, all with normal surrounding mucosa. However, this lesion is commonly missed as illustrated by our case and the initial endoscopy is diagnostic in only 63% of cases.1 It is potentially life threatening and massive haemorrhage can occur with erosion of the mucosa and arterial wall.
Q2: What is the most appropriate endoscopic haemostatic method?
The study by Norton et al suggests endoscopic haemostasis was achieved in 94% of cases.1 Various endoscopic haemostatic methods have been advocated but most experience has been with thermal ablation (heater probe), which should be available in most centres. Long term recurrence was not evident after successful endoscopic ablation.1 A recent study advocates endoscopic haemoclip application as an alternative effective and safe method with long term benefits.2 Our patient was initially treated with an injection of epinephrine to slow down the bleeding rate followed by thermal ablation to achieve haemostasis (fig 1 below). The patient made an uneventful recovery with no further bleed within six months of follow up.