Outcomes in Severe Upper GI Hemorrhage from Dieulafoy ’s Lesion with Monitoring of Arterial Blood Flow
AbstractBackgroundDieulafoy ’s lesion (DL) is a rare but increasingly recognized cause of severe upper GI hemorrhage (SUGIH). There is little consensus regarding the endoscopic approach to management of bleeding from DL.AimsOur purposes were to compare 30-day outcomes of patients with SUGIH from DL with Doppler endoscopic probe (DEP) monitoring of blood flow and guided treatment versus standard visually guided hemostasis (VG).MethodsEighty-two consecutive DL patients with SUGIH were identified in a large CURE Hemostasis database from previous prospective cohort studies and two recent RCTs at two university-based medical centers. 30-day outcomes including rebleeding, surgery, angiography, death, and severe medical complications were compared between the two treatment groups.Results40.2% of DL bleeds occurred in inpatients. 43.9% of patients had cardiovascular disease, and 48.7% were taking medications associated with bleeding. For the entire cohort, 41.3% (26/63) of patients treated with VG had a composite 30-day outcome as compared to 10.5% (2/19) of patients treated with DEP (p = 0.017). Rebleeding occurred within 30 days in 33.3% and 10.5% of those treated with VG and DEP, respectively (p = 0.051). After propensity score matching, the adjusted 30-day composite outcome occurred in 39.0% in the VG group compared to 2.6% in the DEP group (p
CONCLUSIONS: Endoscopic hemostasis was achieved in the majority of patients with high-risk ulceration, although the occurrence of rebleeding is a significant challenge, especially in patients with duodenal ulcers. Clinical trial registration: Bleeding Ulcer and Erosions Study (BLUE Study), ClinicalTrials.gov identifier: NCT03367897.PMID:34663154 | DOI:10.1080/00365521.2021.1988701
ConclusionVCE has a high detection rate of SB lesions (84)%. CTE has a low significance in detection of SB vascular lesions and CT mesenteric angiography sensitivity relatively low. AVMs more common with increasing the age. PHE and SB ectopic varicies, were found to be common causes of GIT bleeding in CLD patient. There is a significant rate of missed gastric and duodenal (proximal to the papilla) lesions that the cause of GIT bleeding and unexplained iron deficiency anemia in OGD examination that were detected by VCE.
We present two patients, one with chronic pancreatitis and one with acute pancreatitis, both complicated with severe upper GI tract bleeding. Patients were successfully treated with transcatheter embolization after initial endoscopic hemostasis failed. The advances in endovascular devices and embolization materials and increased number of experienced interventional radiologists have increased the importance of angiographic embolization procedures as a safe minimally invasive therapeutic method of achieving successful hemostasis associated with the low incidence of complications. Due to its advantages over surgery, it shoul...