Long term follow-up of Dieulafoy lesion

Dieulafoy lesion (exulceratio simplex) is an important but relatively uncommon cause of life-threatening gastrointestinal hemorrhage. Optimal treatment remains uncertain and long term follow-up of these patients has not been reported. Aim: To determine the long-term outcome of endoscopic therapy for Dieulafoy lesion. Methods: Patients with a diagnosis of Dieulafoy lesion were identified from our GI Bleed Team prospective data base. Information regarding diagnosis, treatment and outcomes was derived from the database, patient records and follow-up correspondence. Results: Between October 1988 and July 1997, 90 Dieulafoy lesions were identified by endoscopy in 89 patients after a mean of 1.5 procedures (range: 1-4 ); 59% of patients were male; the mean age was 70.3 years (range 30-94). Lesions were located in the stomach (66%), duodenum (20%), colon (10%), jejunum (2c/( ), and esophagus (2%). Mean transfusion requirement was 6.1 units (range: 0-24). Two patients exsanguinated and 3 required urgent surgery, all others were initially successfully treated endoscopically. Initial endoscopic therapy utilized heater probe in 70 patients; band ligation in 3; hemoclip in 1; laser in 2; gold probe in 2 and sclerotherapy in 2. Epinephrine injection preceded use of thermal modalities in 86% of cases and was sole therapy in 4 patients. latrogenic perforation in the gastric fundus occurred in 1 patient 5 days after sclerotherapy with tetradecylsulfate. In-hospital rebleeding occurred on 11 occasions in 9 patients, one of whom underwent surgery. Median time until rebleed was 6 days (range 1-28). Nine patients died during hospitalization: 4 directly related to to the bleeding event (2 exsanguination; 1 arrhythmia and 1 cardiac failure) and 5 related to preceding co-morbidity. No deaths resulted from rebleeding. During a mean follow-up of 24.5 months (range 0-98), 34 patients (38%) died; 30 day mortality was 12 ( 13%), all of whom had significant co-morbidity [cardiovascular (7), malignancy (3) or cirrhosis (5)]. One patient rebled from a recurrent Dieulafoy lesion 6 yrs after surgical oversewing of a lesion at the same site. No delayed rebleeding occurred in patients treated solely with endoscopic therapy. Conclusions: Dieulafoy lesions are relatively common, accounting for 2% of acute GI bleeding. They are mainly a disease of the elderly. One third are extra-gastric. Endoscopie therapy utilizing combined injection and thermal modalities is both safe and effective. Although 30 day and longer term mortality are high, they are usually related to co-morbidity. Long term recurrence is rare, and did not occur after endoscopic ablative therapy.