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)