Chronic gastrointestinal bleeding caused by a Dieulafoy’s lesion in the small intestine: a case report

Introduction Dieulafoy’s lesion, first found by Paul Georges Dieulafoy, is an infrequent but important cause of recurrent upper gastrointestinal bleeding. The bleeding is usually severe, but patients rarely present with chronic, occult gastrointestinal bleeding. Case presentation In this article, we discuss the case of a 68-year-old caucasian man with a history of recurrent hematemesis and chronic anemia with evidence of extravasation of contrast in the lumen of the bowel loop on computed tomography angiography. The patient was taken to the operating room, and a laparotomy procedure was performed. Conclusion Due to the infrequency of Dieulafoy’s lesion compared with other causes of gastrointestinal bleeding, it is often missed in the process of differential diagnosis. In this article, we have demonstrated the importance of this disease and different approaches to the treatment of this lesion, considering the location of the lesion among other factors.

Diagnosis in suspected gastrointestinal disease

The most frequent presenting complaints suggesting gastrointestinal disease are diarrhoea, constipation, nausea, vomiting, anorexia, and abdominal pain, which can localize to any of the quadrants of the abdomen observed from the front. Loss of weight is a feature of some gastrointestinal diseases, and general symptoms such as fever, malaise, and arthralgia may also occur. According to the National Institute for Clinical Excellence (NICE), alarm symptoms include unintentional weight loss, dysphagia, chronic gastrointestinal bleeding, iron deficiency anaemia, an abdominal mass, and/or persistent vomiting.

When to abandon the search for an elusive gastrointestinal bleeding source

Background and study aims In some patients with gastrointestinal bleeding, even multiple consecutive endoscopic procedures fail to achieve lasting hemostasis. The current decision analysis was designed to answer the question of when to continue or abandon a sequence of endoscopic attempts of endoscopic hemostasis. Materials and methods A decision tree with a threshold analysis was used to model the decision between continued endoscopy or expectant management. A low threshold probability was indicative of a preferred management option. Results For continued endoscopy to be the favored decision, its probability of success in achieving hemostasis needed to exceed the success probability of expectant management by a greater amount than its costs exceeded those of expectant management. Endoscopic attempts at hemostasis should be discontinued if the costs of endoscopy are high compared with those of expectant management. The endoscopic attempt should be continued, if its probability for achieving lasting hemostasis is high. Conclusions Such principles are applicable as rule of thumb in managing patients with ongoing chronic gastrointestinal bleeding.

Insights into the management of gastric antral vascular ectasia (watermelon stomach)

Gastric antral vascular ectasia (GAVE) is an uncommon but important cause of chronic gastrointestinal bleeding. It is often associated with systemic diseases such as autoimmune diseases, liver cirrhosis, chronic renal insufficiency and cardiovascular disease. The etiology of GAVE has not been fully explored and remains controversial. Diagnosis is mainly based on endoscopic presentation with flat or raised erythematous stripes radiating from the pylorus to the antrum and resembles a watermelon. Clinical presentation may range from iron-deficiency anemia secondary to occult blood loss, melena to hematemesis. In past decades, many therapeutic modalities including medical, endoscopic and surgical intervention have been introduced for GAVE treatment with variable efficacy. Herein, we review the efficacy and safety of these treatment options for GAVE.

Acute on chronic gastrointestinal bleeding: a unique clinical entity

Gastrointestinal bleeding is defined in temporal–spatial terms—as acute or chronic, and/or by its location in the gastrointestinal tract. Here, we define a distinct type of bleeding, which we have coined ‘acute on chronic’ gastrointestinal bleeding. We prospectively identified all patients who underwent endoscopic evaluation for any form of gastrointestinal bleeding at a University Hospital. Acute on chronic bleeding was defined as the presence of new symptoms or signs of acute bleeding in the setting of chronic bleeding, documented as iron deficiency anemia. Bleeding lesions were categorized using previously established criteria. We identified a total of 776, 254, and 430 patients with acute, chronic, or acute on chronic bleeding, respectively. In patients with acute on chronic gastrointestinal bleeding, lesions were most commonly identified in esophagus (28%), colon and rectum (27%), and stomach (21%) (p<0.0001 vs locations for acute or chronic bleeding). In those specifically with acute on chronic upper gastrointestinal bleeding (n=260), bleeding was most commonly due to portal hypertensive lesions, identified in 47% of subjects compared with 29% of acute and 25% of chronic bleeders, (p<0.001). In all patients with acute on chronic bleeding, 30-day mortality was less than that after acute bleeding alone (2% (10/430) vs 7% (54/776), respectively, p<0.001). Acute on chronic gastrointestinal bleeding is common, and in patients with upper gastrointestinal bleeding was most often a result of portal hypertensive upper gastrointestinal tract pathology. Reduced mortality in patients with acute on chronic gastrointestinal bleeding compared with those with acute bleeding raises the possibility of an adaptive response.