International Journal of Surgery Case Reports 114 (2024) 109166

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Dieulafoy's lesion: Is there still a place for surgery? About 2 cases

Souhaib Atri, Mahdi Hammami *, Yacine Ouadi, Amine Sebai, Youssef Chaker, Montassar Kacem
Department, Hopital la Rabta, Tunis, Tunisia

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Dieulafoy's lesion, a rare but life-threatening condition accounting for a small percentage of acute
Dieulafoy's lesion gastrointestinal bleeding cases, has historically posed diagnostic and therapeutic challenges.
Hemorrhage Case presentation: In this article, we present two cases that required surgical intervention due to unsuccessful
Endoscopy
attempts with endoscopy. Case 1 involved a 40-year-old patient with a history of treated duodenal ulcers, while
Surgical treatment
Case 2 featured a 74-year-old woman with no notable medical history. Both patients exhibited severe bleeding,
necessitating urgent surgical procedures. The surgical approach involved wide gastrotomy, careful inspection,
and successful suturing of the bleeding vessel.
Discussion: Dieulafoy lesions, discovered by French surgeon Georges Dieulafoy in 1885, constitute 1–2 % of acute
gastrointestinal bleeding cases. These anomalies involve enlarged submucosal arteries, predominantly in the
stomach, but occurrences in other sites are documented. Endoscopic methods, surpassing surgical intervention,
are preferred for treatment, boasting success rates over 90 %. Surgical measures become a last resort for un­
controlled bleeding, with laparoscopic surgery emerging as a minimally invasive alternative, facilitated by
various intra-operative localization techniques. Laparoscopic wedge resection, in particular, exhibits lower re-
bleeding rates than traditional oversewing methods, although feasibility depends on lesion location.
Conclusion: While endoscopic methods are preferred, surgery remains a vital option when bleeding persists or
endoscopic intervention fails. This report highlights the significance of surgical management in selected cases of
Dieulafoy's lesion.

1. Introduction 2. Case 1

Over time, the management approach for Dieulafoy's lesion has un­
dergone significant advancements. In the past, when endoscopy was not
yet available, radical surgeries like subtotal or total gastrectomies were
commonly employed, despite their associated high morbidity rates [1].
However, with the advent of endoscopy, the management of bleeding
from Dieulafoy's lesion has predominantly shifted towards this less
invasive procedure, yielding superior outcomes. Consequently, the role
of surgery has been considerably diminished [2], although it still retains
its significance in cases of refractory bleeding and uncontrollable
massive bleeding. In this report, we present two cases of Dieulafoy's
lesion that necessitated surgical intervention due to unsuccessful at­
tempts with endoscopy.
This work was reported in line with the SCARE guidelines [3].
A 40-year-old patient was admitted to the intensive care unit for
severe upper gastrointestinal bleeding manifested as hematemesis. He
had a history of a treated duodenal ulcer and had been taking ace­
tylsalicylic acid for joint pain for a few days.
Upon admission, the patient was pale and tachycardic, with a blood
pressure of 80/50, necessitating the use of catecholamines. The hemo­
globin level was 5 g/L. Given the patient's medical history, a recurrent
bleeding episode from the duodenal ulcer was suspected. Endoscopic
hemostasis was not feasible because there was massive bleeding and the
source of hemorrhage couldn't be identified despite the presence of a
scarred ulcer in the duodenum with no signs of hemorrhage.
A wide gastrotomy was performed. After removing multiple blood
clots, careful inspection of the gastric mucosa revealed a visibly pro­
truding vessel in the fundus with diffuse bleeding. This was treated by
suturing (Fig. 1). A total of 6 units of packed red blood cells were
administered.

* Corresponding author.
E-mail address: mahdi.hammami@etudiant-fmt.utm.tn (M. Hammami).

https://doi.org/10.1016/j.ijscr.2023.109166
Received 20 November 2023; Accepted 8 December 2023
Available online 15 December 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
S. Atri et al.
Fig. 1. a: Protruding vessel (black arrow).
The postoperative period was uneventful, and the patient was dis­
charged from the hospital on the 8th day after surgery. He was doing
well at 1-year follow-up.
3. Case 2
A 74-year-old woman was admitted to the hospital due to melena
accompanied by severe anemia. He had no notable medical history and
denies the use of non-steroidal anti-inflammatory drugs.
Upon admission, the clinical examination revealed paleness of the
skin and mucous membranes, stable hemodynamic status, a soft
abdomen, and the presence of dark-colored stool during the rectal ex­
amination. Laboratory tests showed microcytic hypochromic anemia
with a hemoglobin level of 7 g/dL, a platelet count of 150,000/mm3, a
prothrombin level of 85 %, and normal liver and kidney function.
Upper endoscopy was conducted revealing no source of hemorrhage
in the stomach and the duodenum. 3 units of packed red blood cells were
administered. The hemoglobin level was 9.5 g/dL.
24 h later, the patient presented massive hematemesis. And hemo­
globin level dropped to 6 g/dL.
Upper endoscopy revealed a visible vessel in the subcardial region
with a blood clot treated with a hemoclip. The patient received two
additional units of packed red blood cells. However, the patient had a
second episode of hematemesis a few hours later along with signs of
hypovolemic shock, including a blood pressure of 70/40 mmHg, a heart
rate of 150 bpm, sweating, and a decrease in hemoglobin level to 4.5 g/
dL. This required a transfusion of 4 units of packed red blood cells, a
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International Journal of Surgery Case Reports 114 (2024) 109166
macromolecule infusion, and the administration of catecholamines.
An urgent surgery was decided, and during the operation, after
gastrotomy, the extraction of several blood clots revealed active
bleeding from a small erosion in the subcardial region, suggestive of a
diagnosis of Dieulafoy's ulcer (Fig. 2) treated by suturing. The patient
was discharged on the fifth postoperative day and was doing well at 6-
month follow-up.
4. Discussion
The Dieulafoy lesion is a critical condition that poses a significant
risk to life, resulting in substantial morbidity and mortality. It accounts
for approximately 1 % to 2 % of cases of acute gastrointestinal bleeding
[4]. Discovered by the esteemed French surgeon Georges Dieulafoy in
1885 [5], this lesion consists of an enlarged, anomalous submucosal
artery that breaches the epithelium, leading to severe and recurrent
bleeding. Although these lesions are typically found in the stomach,
there have been documented instances in the medical literature of extra-
gastric Dieulafoy lesions [6]. Notably, one case report highlighted the
presence of two synchronous lesions in the stomach and jejunum of a 15-
year-old patient, which is an uncommon presentation given that these
lesions predominantly affect the elderly population [7].
Dieulafoy lesions are commonly situated in the proximal lesser cur­
vature of the stomach, accounting for at least 71 % of reported cases [4].
However, they have also been observed in other locations such as the
esophagus, duodenum, jejunum, ileum, colon, rectum, and anal canal.
Among these alternative locations, the duodenum and colon rank as the
second and third most frequent sites, respectively [8]. While bleeding
from Dieulafoy lesions is typically self-limiting, it often recurs and can
be severe enough to endanger the patient's life. Diagnostic challenges
during endoscopy arise due to the small size of the lesion, its relatively
inaccessible location, the absence of ulcers, and the presence of blood
and blood clots.
The typical morphological characteristics of a Dieulafoy lesion
involve a large-diameter vascular stump (generally 1 to 3 mm) pro­
truding through a small erosion (2 to 5 mm) in the mucosa, which is
usually covered in clots. This erosion may exhibit pulsatile bleeding or
present as a jet or intermittent bleeding. In the past, surgical resection,
such as gastrotomy and wide-wedge resection or gastrectomy, was the
primary treatment for Dieulafoy's lesions. However, advancements in
endoscopic procedures have now superseded surgical intervention.
Endoscopic methods are the preferred treatment for easily accessible
lesions, with reported success rates exceeding 90 % [4,8,9]. Endoscopic
hemostatic procedures can be categorized into three groups: 1) thermal-
electrocoagulation, heat probe coagulation, and argon plasma coagu­
lation; 2) regional injection, including local epinephrine injection and
sclerotherapy; and 3) mechanical techniques like banding and hemoclip
application. Each technique has its own advantages and disadvantages
in terms of hemostatic efficacy and technical aspects, leading to varying
success rates. Evidence in the literature suggests that mechanical he­
mostatic methods during endoscopy are more effective compared to
injection or thermal treatments [10]. Additionally, combined endo­
scopic therapies have shown lower re-bleeding rates compared to
endoscopic monotherapy [2].
Surgery is considered a last resort for patients with uncontrolled
bleeding from Dieulafoy lesions or when the bleeding site cannot be
identified via endoscopy, or when bleeding persists despite multiple
endoscopic treatments. Salvage surgery has been required in 3 % to 16 %
of patients in the published series [2]. Surgical procedures currently
employed include oversewing of the lesion or wedge resection of the
affected section. In our cases, suturing effectively controlled the
bleeding, with no recurrence in the long term.
Some authors suggest that surgical resection remains preferable.
Surgical oversewing of the vessel is associated with a higher risk of
recurrent bleeding, and wedge resection of the affected segment may be
a better surgical option for patients with refractory bleeding [1,11].
S. Atri et al.
Fig. 2. : Bleeding vessel (black arrow).
Wide gastrotomy is recommended to remove clots and provide a clear
view of the gastric mucosa. In our cases, a large gastroduodenotomy was
made for better exposure of the mucosa and extraction of blood clots. If
the bleeding point is not evident, wiping the mucosa with a dry gauze
may induce hemorrhage and reveal the lesion. Careful palpation of the
stomach can sometimes detect the thickened blood vessels and clots
associated with the Dieulafoy lesion. It is important to note that vagot­
omy is not necessary, and “blind” resection or subtotal gastrectomy is
not recommended, as the lesion may not be included in the resected part,
and massive recurrent bleeding has been reported after such surgeries
[1]. The reported mortality rate following surgical intervention remains
high, up to 33 % [11].
While most patients requiring surgery have traditionally undergone
laparotomy, laparoscopic surgery has recently been described for the
removal of these lesions [12]. Laparoscopic surgery presents an attrac­
tive option for treating Dieulafoy lesions, as it offers a curative approach
with minimal invasiveness for the patient. However, successful laparo­
scopic resection relies on accurate localization of the bleeding site [13].
Several case reports in the literature describe successful laparoscopic
wedge resection of bleeding Dieulafoy lesions in the stomach following
pre-operative or intra-operative localization [12,14].
Accurate intra-operative localization of these lesions can be chal­
lenging. Various methods have been proposed to ensure precise locali­
zation. One approach involves intra-operative endoscopy, which allows
real-time visualization and localization of the bleeding lesion. After
pneumoperitoneum induction, upper gastrointestinal endoscopy is per­
formed. The laparoscopic light is dimmed or turned off, and the
gastroscope is used to identify and mark the bleeding lesion with clips or
sutures. Subsequently, resection is performed [12]. Mixter et al. [15]
described a combined endoscopy and laparoscopy approach to identify
and ligate the artery supplying the bleeding Dieulafoy lesion, without
the need for resection.
Laparoscopic wedge resection has been reported to have a lower re-
bleeding rate compared to oversewing the Dieulafoy lesion (36). How­
ever, wedge resection may not be feasible for lesions located within 6 cm
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International Journal of Surgery Case Reports 114 (2024) 109166
of the gastroesophageal junction. In such cases, oversewing the lesion or
laparoscopic clip placement on the vessel supplying the lesion may be a
better option. Alva et al. [12] described pre-operative localization of the
lesion using tattooing with India ink and clips, which allows for accurate
localization and obviates the need for intra-operative endoscopy. Con­
cerns about clip displacement before surgical intervention have not been
reported, and the use of clips for pre-operative localization of the lesion
has not been associated with interference with stapling devices or
disruption of the staple line during wedge resection.
5. Conclusion
Dieulafoy's lesion should be included in the differential diagnosis of
obscure gastrointestinal bleeding even though it accounts for less than 2
% of all cases of acute GI bleeding. Full awareness of this disease and
careful endoscopy are essential for diagnosis. Repeat endoscopies may
be necessary to establish the diagnosis. There is no doubt that the pri­
mary management of Dieulafoy's lesion is endoscopic. However, surgery
is the only option for patients who fail endoscopic management.
Consent for publication
Written informed consent was obtained from the patients for publi­
cation of this case report and any accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal.
Ethical approval
Not applicable. Our institution requires no ethical approval for case
reports.
Funding
Not applicable.
S. Atri et al. International Journal of Surgery Case Reports 114 (2024) 109166

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