A bleeding stomach - Dieulafoy's Lesion

A 67-year-old man was admitted after 1 day of melena and hematemesis. Thirty years earlier, he had undergone a Billroth type I operation (gastroduodenostomy) for treatment of peptic ulcer disease. Gastroscopy revealed a spurting vessel in the duodenum, just beyond the gastroduodenal anastomosis. Injection of epinephrine and the use of endoscopic clips (arrow) led to complete cessation of bleeding. Since there was no evidence of duodenal ulceration or varices, the bleeding vessel was diagnosed as a duodenal Dieulafoy's lesion. 

A Dieulafoy's lesion is an aberrantly dilated and tortuous submucosal arteriole, often identified after it erodes through the mucosa of the gastrointestinal tract and begins to bleed. It was named after the French surgeon Paul Georges Dieulafoy, who described the condition in 1898. Dieulafoy's lesions are thought to be congenital vascular malformations and are most frequently found in the stomach. This patient had an uneventful recovery and had had no recurrence of bleeding at a 9-month follow-up visit.

Discussion

Upper gastrointestinal (UGI) bleeding is a common disorder affecting over 100 per 100 000 population yearly. The most common etiologies include peptic ulcer disease, mucosal erosive disease and variceal bleeding.

There is an increasing concern for cost-containment without sacrificing clinical outcomes; there is room to implement emergent care for UGI bleeding with appropriate early discharge for subjects at low risk of rebleeding or death

The Rockall System is an accurate and valid predictor of rebleeding and death in UGI bleeding.

Rockall score should be applied to assess all patients with suspected bleeding peptic ulcer to determine high risk patient, and arrange for early (within 24 hours after presentation) endoscopy for diagnosis as well as hemostasis if there are presence of active bleeding. Forrest I, possibly Forrest IIa requires endoscopic hemostasis. Mr. ABA is of a candidate for admission and monitoring as well as early endoscopy because he has a score of 4 in clinical Rockall score. Only those with score less than 2 are of low risk and managed as outpatient.

Rockall Score

Age
<60 yr	0
60–79 yr	1
­80 yr	2
Shock
Heart rate >100 beats/min	1
Systolic blood pressure <100 mm Hg	2
Coexisting illness
Ischemic heart disease, congestive heart failure, other major illness	2
Renal failure, hepatic failure, metastatic  cancer	3
Endoscopic diagnosis
No lesion observed, Mallory–Weiss tear	0
Peptic ulcer, erosive disease, esophagitis	1
Cancer of upper GI tract	2
Endoscopic stigmata of recent hemorrhage
Clean base ulcer, flat pigmented spot	0
Blood in upper GI tract, active bleeding, visible vessel, clot	2

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