Abdominal haemorrhage, a common and life-threatening condition, can result because of several causes. The two main causes include blunt trauma and benign gynaecological disease, while the less frequent aetiologies include neoplastic, inflammatory and vascular lesions.3
Common vascular disorders include variceal rupture in patients with portal hypertension, inflammatory vasculitis such as polyarteritis nodosa and rupture of aortic or mesenteric aneurysms.4
Dieulafoy’s lesion is a kind of vascular malformation, which although fairly uncommon is a clinically significant cause of upper gastrointestinal haemorrhages. It usually presents with intragastric haemorrhage rather than bleeding into the abdominal cavity.
Dieulafoy’s lesion was first described by Gallard in 18845
and later named after the French surgeon Dieulafoy.6
It is typically seen in men, especially in those of advanced age. The patient often had no peptic ulcer, cirrhosis or alimentary canal tumours, and no pre-symptoms of digestive tract have been identified thus far. The lesions most commonly occur on the lesser curvature of the stomach, within 6 cm of the gastro-oesophageal junction; however, lesions have also been reported in the antrum, oesophagus, duodenum, jejunum, caecum, colon and rectum.2,7–10
At present, the aetiology of Dieulafoy’s lesion is unknown and it is primarily considered to be congenital. Typically, the lesion consists of a large calibre tortuous artery, 1–3 mm in diameter, which lies in the submucosa in close contact with the mucosa over a variable distance.7,11
Overlying mucosal erosions or other factors may result in artery rupture causing a lethal haemorrhage. Dieulafoy’s lesion is very difficult to diagnose and, generally, endoscopy is the first choice for diagnosis as well as treatment. The endoscopic diagnosis of Dieulafoy’s lesion is based on the following established criteria: (1) active arterial spurting or micropulsatile streaming from a tiny (<3 mm) mucosal defect; (2) visualisation of a protruding vessel with or without active bleeding within a minute mucosal defect with normal surrounding mucosa; or (3) a densely adherent clot with a narrow point of attachment to a minute mucosal defect or normal-appearing mucosa.2,12
Histological analysis has revealed that the involved blood vessel is a calibre persistent artery penetrating through the mucosa, which subsequently leads to massive haemorrhage. These arteries can be tortuous and can be accompanied by venous blood vessels; however, these arteries do not show any pathological changes consistent with arteriovenous malformation or arteriosclerosis, such as inflammation. A superficial mucosal defect or erosion is found in the mucosa overlying the artery.1,7,12
It was previously thought that Dieulafoy’s lesion may represent a congenital vascular malformation similar to arteriovenous malformation.
Unfortunately, the patient did not undergo gastroscopy before the operation; hence, we were unable to ascertain whether there was any mucosal ulceration or defect in the gastric mucosa. However, on the basis of his symptom history, the laboratory analysis and the pathology examination, we can conclude that mucosal ulcer, defects or other changes would have been unlikely. His major symptom was abdominal haemorrhage and, to the best of our knowledge, this is a novel and unique clinical presentation that has not yet been reported in the literature. Although the association did not result in a management change, the factors that led to the haemorrhage were unknown. This report presents novel findings for diagnosing this disease, and may contribute to further studies on the pathogenesis of Dieulafoy’s lesion.
- Further studies on the pathogenesis of Dieulafoy’s lesion is required.
- Some people, especially older people, often have atypical symptoms that lead to misdiagnosis.
- Related examinations should be carried out if the patient’s condition allows it.