Arteriographic diagnosis and treatment of gastric Dieulafoy lesion

Clinical History

A 66-year-old male patient presented with a history of recurrent serious gastric fundus bleeding, not successfully treated endoscopically with n-Butyl-2 Cyanoacrylat.
He was referred from an outside hospital to the Interventional Radiology department for a Transjugular Intrahepatic Portosystemic Shunt (TIPS) with the goal of secondary prophylaxis of a presumed variceal haemorrhage.

Imaging Findings

A careful review of our Department of the image findings (abdominal ultrasound with Doppler and contrast-enhanced CT) did not reveal signs of portal hypertension nor of cirrhosis; but instead a Dieulafoy lesion of the gastric fundus.
Arteriography was performed, with selective catheterization of the left gastric artery (which originates independently from the abdominal aorta) demonstrating a tortuous and voluminous arterial hypertrophy at the gastric fundus, which communicated with the spleen by way of the short gastric arteries. No early venous return was identified.
The selected course of treatment was superselective embolization with 3 vials of the liquid embolization agent SQUID 18. Control arteriogram confirmed the exclusion of the large lesion.
Arteriography of the superior mesenteric artery revealed exuberant collateral splenic circulation revascularizing the short gastric arteries and the splenic artery, and collateral pancreatic-duodenal circulation, revascularizing the gastroduodenal and hepatic arteries.
The coeliac trunk was not identified, indicating arteriosclerotic occlusion of its origin.

Discussion

A Dieulafoy lesion consists of a tortuous, submucosal artery in the gastrointestinal tract, which penetrates, erodes and eventually perforates the mucosa over time, causing severe gastrointestinal bleeding [1]. The reported incidence ranges from 0.3 to 6.7% [2, 3]. It affects all age groups and both genders, but with a higher reported incidence in male patients above 60 years [3-7]. The proximal stomach is the most common site, classically in the lesser curvature [3, 6]. One out of three cases is found to occur outside the stomach, with the duodenum and the colon being the second and third most common locations, respectively [4]. It is an uncommon cause of upper gastrointestinal haemorrhage, representing 4% of the cases [5].
Because it usually causes periodic but severe bleeding and it represents a rather challenging endoscopic diagnosis, Dieulafoy lesion has a high mortality rate [1].
Endoscopy is the current standard method for diagnosis and treatment - epinephrine injection and electrocautery are the options most commonly used [7].
Angiographic findings include extravasation of contrast from an eroded artery that may appear normal otherwise, but the most common finding is tortuous ectatic arteries in the territory of the left gastric artery with no associated early venous return [4, 7].
Selective arteriography with embolization is the treatment of choice in patients who fail endoscopic therapy (as in this case); are not adequate surgical candidates; or have acute lower GI bleeding or lesions beyond the reach of the therapeutic endoscope [7].
The long-term prognosis of a properly treated Dieulafoy disease is favourable, and almost identical between the three modalities [5, 7-10].
Dieulafoy disease has the potential to be challenging both in diagnostic and therapeutic terms. It should be suspected if the workup of patients with GI bleeding finds extravasation from a tortuous dilated artery with otherwise normal features and found not to be associated with large draining veins [4].
Currently there is enough evidence to advocate transcatheter arterial embolization in Dieulafoy lesions, particulary gastric, prior to surgery, as a less invasive therapeutic option [4, 8-10].
A wide range of embolic agents are available, which can be classified as temporary or permanent. This case required permanent vessel occlusion, achieved with nonabsorbable microparticles (e.g. polyvinyl alcohol), mechanical agents (e.g. coils) or liquid agents (e.g. ethylene vinyl alcohol (SQUID)) [11]. Due to the need of embolization distal to the catheter tip and our Department's vast experience on the administration of liquid agents, SQUID was safely and successfully used.

Differential Diagnosis List

Final Diagnosis

Dieulafoy lesion of the gastric fundus.

URL:	https://eurorad.org/case/14172
DOI:	10.1594/EURORAD/CASE.14172
ISSN:	1563-4086