Nojkov Borko, Cappell Mitchell S
Borko Nojkov, Mitchell S Cappell, Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States.
World J Gastrointest Endosc. 2015 Apr 16;7(4):295-307. doi: 10.4253/wjge.v7.i4.295.
Although relatively uncommon, Dieulafoy's lesion is an important cause of acute gastrointestinal bleeding due to the frequent difficulty in its diagnosis; its tendency to cause severe, life-threatening, recurrent gastrointestinal bleeding; and its amenability to life-saving endoscopic therapy. Unlike normal vessels of the gastrointestinal tract which become progressively smaller in caliber peripherally, Dieulafoy's lesions maintain a large caliber despite their peripheral, submucosal, location within gastrointestinal wall. Dieulafoy's lesions typically present with severe, active, gastrointestinal bleeding, without prior symptoms; often cause hemodynamic instability and often require transfusion of multiple units of packed erythrocytes. About 75% of lesions are located in the stomach, with a marked proclivity of lesions within 6 cm of the gastroesophageal junction along the gastric lesser curve, but lesions can also occur in the duodenum and esophagus. Lesions in the jejunoileum or colorectum have been increasingly reported. Endoscopy is the first diagnostic test, but has only a 70% diagnostic yield because the lesions are frequently small and inconspicuous. Lesions typically appear at endoscopy as pigmented protuberances from exposed vessel stumps, with minimal surrounding erosion and no ulceration (visible vessel sans ulcer). Endoscopic therapy, including clips, sclerotherapy, argon plasma coagulation, thermocoagulation, or electrocoagulation, is the recommended initial therapy, with primary hemostasis achieved in nearly 90% of cases. Dual endoscopic therapy of epinephrine injection followed by ablative or mechanical therapy appears to be effective. Although banding is reportedly highly successful, it entails a small risk of gastrointestinal perforation from banding deep mural tissue. Therapeutic alternatives after failed endoscopic therapy include repeat endoscopic therapy, angiography, or surgical wedge resection. The mortality has declined from about 30% during the 1970's to 9%-13% currently with the advent of aggressive endoscopic therapy.
尽管Dieulafoy病相对少见，但因其诊断常存在困难、易导致严重的、危及生命的反复胃肠道出血，且适合进行挽救生命的内镜治疗，所以它是急性胃肠道出血的一个重要原因。与胃肠道正常血管外周口径逐渐变细不同，Dieulafoy病损尽管位于胃肠道壁的外周黏膜下层，但其口径却保持较大。Dieulafoy病通常表现为严重的、活动性胃肠道出血，且无前驱症状；常导致血流动力学不稳定，常需输注多个单位的浓缩红细胞。约75%的病损位于胃，沿胃小弯在胃食管交界处6 cm范围内的病损有明显的倾向性，但病损也可发生于十二指肠和食管。空肠回肠或结直肠的病损报道日益增多。内镜检查是首要的诊断方法，但诊断阳性率仅为70%，因为病损常常较小且不明显。病损在内镜下通常表现为暴露血管残端的色素性隆起，周围仅有轻微糜烂且无溃疡形成（可见血管无溃疡）。内镜治疗，包括使用夹子、硬化剂注射、氩离子凝固术、热凝术或电凝术，是推荐的初始治疗方法，近90%的病例可实现初步止血。肾上腺素注射后再行消融或机械治疗的双重内镜治疗似乎有效。尽管据报道套扎术非常成功，但套扎深层壁组织有小的胃肠道穿孔风险。内镜治疗失败后的治疗选择包括重复内镜治疗、血管造影或手术楔形切除术。随着积极的内镜治疗的出现，死亡率已从20世纪70年代的约30%降至目前的9% - 13%。
