A common case of haematemesis in ER rarely caused by gastroenteric bleeding: Dieulafoy’s lesion

A 76 years old man came in our emergency department because
of two episodes of haematemesis. About your gastrointestinal
system, during the last gastroscopy, it was revealed gastric
atrophy, hernia of the esophageal hiatus and a light teleangectasia
in the posterior wall of the stomach. On admission, there was
severe anaemia (Hb = 4,7 g/dl). He was immediately transfused
with two units of blood (concentrated red cells) type 0 negative.
The subsequent gastroscopy revealed an haemorrage in the posterior
wall of the stomach as in the case of Dieulafoy’s lesion. It
was treated with an injection of epinephrine (1:10.000) during
the same gastroscopy. After numerous blood transfusions, the
course was good and he came back home with specific gastric
teraphy.
Dieulafoy’s lesion is an uncommon cause of gastrointestinal
bleeding (1-2%) with a prevalence in men (M:F = 2:1) and typical
of middle age (about 54 years). It is caused by a spontaneous
rupture of a submucosal gastric small artery but it may also
occur in esophagus, small intestine, colon and rectum. It seems in
relation with particular anatomic and physiologic conditions of
the artery involving in the process as: a large calibre, a tortuos
wall, continuous variations of blood pressure.
At the beginning, the most common symptoms are: haematemesis
and/or melaena, anaemia (8,4-9,2 g/dl). Diagnosis occurs
especially during gastroscopy (82-96% of the cases). In the other
cases, diagnosis occurs during laparotomy or with angiography.
The best choiche of the therapy is the injection of epinephrine
during gastroscopy (85%). In the other cases, teraphy is
based on electrocoagulation, sclerotherapy, laserteraphy, mechanical
“clipping”. The re-bleeding occurs in about 15% of the
cases. In this case, 5% of the patients needs of a complete surgical
intervention. Prognosis is better after the development of the
gastroscopy and endoscopic therapeutical techniques especially if
the cause of bleeding is diagnosed and treated immediately (free
survival time = 28-36 months).