Barosa, R

Bilhim, T

Pereira, JA

Pinto-Marques, P

Pires, S

Repositório do Centro Hospitalar de Lisboa Central, EPE

E-Mail karger@karger.com Endoscopic Snapshot  GE Port J Gastroenterol 2017;24:95–97  DOI: 10.1159/000450902  Dieulafoy’s Lesion: The Role of Endoscopic Ultrasonography as a Roadmap  Rita Barosa a    Sara Pires b    Pedro Pinto-Marques a    José António Pereira c    Tiago Bilhim c   a  Department of Gastroenterology, Hospital Garcia de Orta,  Almada ,  b  Gastroenterology Department, Hospital do Espírito Santo,  Évora , and  c  Radiology Department, Hospital de São José, Centro Hospitalar de Lisboa Central,  Lisbon , Portugal body and fundus. Repeated UGE showed no mucosal de-fect. Radial endoscopic ultrasound (EUS) was performed, indicating a submucosal vessel arising in the greater cur-vature of the proximal gastric body which identified a Dieulafoy’s lesion as the possible source of bleeding. Con-sidering clinical stability, EUS-guided therapy with linear scope was planned for the next morning when the scope was available, but rebleeding occurred. UGE was per-formed with a therapeutic scope, as the site of bleeding was already identified and active bleeding was expected. Thus, the advantages of a dual channel scope, which is more easily maneuvered, would outweigh the advantages of using the echoendoscope, which has the main benefit when the Dieulafoy’s lesion cannot be identified on UGE because it is no longer bleeding. UGE revealed an adher-ent clot in the suspected Dieulafoy’s lesion location previ-ously described on EUS. After the first clip deployment, massive bleeding occurred. Hemostasis was achieved af-ter adrenalin and polidocanol injection and clipping. EUS was performed to confirm vessel obliteration but still identified a large caliber (2.5 mm) feeding vessel arising  Keywords  Gastrointestinal endoscopy · Endosonography · Gastrointestinal hemorrhage · Vascular malformations   Lesão de Dieulafoy: Papel do Mapeamento por Ecoendoscopia  Palavras Chave  Endoscopia gastrointestinal · Endossonografia · Hemorragia gastrointestinal · Malformações vasculares  A 28-year-old man without any remarkable past med-ical history presented with hematemesis and hemody-namic instability. There was no significant past medical history. He denied any medication intake, namely non-steroidal anti-inflammatory drugs, alcohol abuse, or smoking habits. Upper gastrointestinal endoscopy (UGE) revealed fresh blood and a giant clot covering the gastric  Received: July 22, 2016  Accepted after revision: September 16, 2016  Published online: November 22, 2016  Dr. Rita Barosa   Department of Gastroenterology, Hospital Garcia de Orta   Avenida Torrado da Silva   PT–2801-951 Almada (Portugal)  E-Mail a.rita.b   @   gmail.com   © 2016 Sociedade Portuguesa de GastrenterologiaPublished by S. Karger AG, Basel  www.karger.com/pjg Th is article is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND) (http://www.karger.com/Services/OpenAccessLicense). Usage and distribution for commercial purposes as well as any dis-tribution of modifi ed material requires written permission. Barosa/Pires/Pinto-Marques/Pereira/Bilhim  GE Port J Gastroenterol 2017;24:95–97 DOI: 10.1159/00045090296from the splenic artery penetrating the gastric muscularis propria ( Fig. 1 ). Selective splenic artery angiogram as de-termined by EUS was performed, revealing a short gastric artery ectasia and hypervascularization ( Fig. 2 , large ar-row) ending in the previously endoscopically placed clips ( Fig. 2 , small arrow). Superselective transcatheter arterial embolization (TAE) was performed, and the patient pre-sented no further episodes of gastrointestinal bleeding at the 1-year follow-up. Dieulafoy’s lesion is a relatively rare cause of upper gastrointestinal bleeding which may be difficult to detect on endoscopy in the case of nonactive bleeding  [1] . EUS may be used to identify a nonactively bleeding Dieula-foy’s lesion, to perform EUS-guided therapy, and to mon-itor therapy effectiveness  [1, 2] . In fact, it is our practice to perform EUS after inconclusive UGE in a severe upper gastrointestinal bleeding setting, clinically suggestive of Dieulafoy’s lesion origin, and we also systematically per-form EUS after endoscopic therapy to confirm effective vessel obliteration  [3] . When refractory to endoscopic treatment, surgery and TAE should be considered  [1] . Marking the lesion with a metallic clip has accurately guided the endovascular intervention in cases of nonac-tive bleeding ulcer and may be equally useful in the treat-ment of Dieulafoy’s lesions  [4] . With this case, we empha-size the role of EUS as a roadmap for other interventions, such as selective TAE. Fig. 1. Large caliber (2.5 mm) feeding ves-sel arising from the splenic artery penetrat-ing the gastric muscularis propria.  Fig. 2. Selective splenic artery angiogram revealing a short gastric artery ectasia and hypervascularization (large arrow) ending in the previously endoscopically placed clips (small arrow).  Dieulafoy’s Lesion  GE Port J Gastroenterol 2017;24:95–97 DOI: 10.1159/00045090297 References  1 Nojkov B, Cappell MS: Gastrointestinal bleeding from Dieulafoy’s lesion: clinical pre-sentation, endoscopic findings, and endo-scopic therapy. World J Gastrointest Endosc 2015; 7: 295–307.  2 Law R, Fujii-Lau L, Wong Kee Song LM, Gos-tout CJ, Kamath PS, Abu Dayyeh BK, et al: Efficacy of endoscopic ultrasound-guided he-mostatic interventions for resistant nonvari-ceal bleeding. Clin Gastroenterol Hepatol 2015; 13: 808–812.  3 Pinto-Marques P, Gíria J, Brito M, Camacho R, Loureiro R: Unusual cause for upper GI bleeding: a splenic artery aneurysm mimick-ing a Dieulafoy lesion. Role for systematic EUS assessment? Gastrointest Endosc 2010;  71: 845–846.  4 Eriksson LG, Sundbom M, Gustavsson S, Ny-man R: Endoscopic marking with a metallic clip facilitates transcatheter arterial emboliza-tion in upper peptic ulcer bleeding. J Vasc In-terv Radiol 2006; 17: 959–964.   Statement of Ethics  This study did not require informed consent or review/approv-al by the appropriate ethics committee. Disclosure Statement  The authors have no conflicts of interest to declare. 

Lesão de Dieulafoy: Papel do Mapeamento por Ecoendoscopia

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Lesão de Dieulafoy: Papel do Mapeamento por Ecoendoscopia

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Repositório do Centro Hospitalar de Lisboa Central, EPE

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