Endoscopic Ligation Therapy of Dieulafoy Ulcer

Lee, Sang In; Kim, Young Soo; Hahm, Ki Baik; Kim, Jin Hong; Park, Jong Suk; Lee, Nae Hee; Park, Young Sook

Abstract

Dieulafoy ulcer is an unusual cause of massive, recurrent and frequently fatal gastrointestinal hemorrhage that results from erosion of abnormally large submucosal artery. Although the lesion has been found throughout the gastrointestinal tract, it most commonly occurs in the proximal stomach. Diagnosis depends on the observation of protruding and eroded artery with pulsatile bleeding or adherent thrombus by endoscopy. Even during active bleeding, the endoseopic examination can be negative if intraluminal blood or clots obscure the source of bleeding. If the bleeding has stopped, the small mucosal lesion can be easily overlooked. Unlike peptic ulceration, there is no excavation of the mucosa. A 76-year-old man presented with massive hematemesis and melena. The patient had no previous history of peptic ulcer disease. He did not drink alcohol and use aspirin or NSAIDs. Physical examination revealed a pale, severely diaphoretic male with hypotension and melenic stools. He was found to have hemoglobin 4.0 g/dL and hematocrit 12.7%. We performed emergency endoscopy which showed a pulsatile and bleeding exposed artery without evidence of surrounding ulcerative lesion on the posterior wall of upper body of stomach. Endoscopic ligation using O ring of Stiegman-Goff endoscopic ligator kit was done successfully and the bleeding stopped immediately after ligation. Ten days after treatment, endoscopy showed artificial ulcerative lesion on previous ligated site and no evidence of bleeding. Another endoscopy four days later revealed healing ulcerative lesion. After improvement, the patient was discharged and rebleeding has not occurred to date.