اجابةcase 8

موضوع: اجابةcase 8 الثلاثاء مارس 31, 2009 10:18 pm

و ارحب باى كومنتات او اضافاتشكرا يا شباب للى فكر و حاول و يا رب الباقى يدلو بدلوه معانا

The findings in this case are consistent with a Dieulafoy lesion of the small bowel, probably in the midjejunum. Dieulafoy lesion is also known as exulceratio simplex, caliber-persistent artery, gastric arteriosclerosis, submucosal arterial malformation, and cirsoid aneurysm of the gastric vessels. Unlike most other aneurysms, Dieulafoy lesions are thought to be developmental malformations rather than degenerative changes. In 1898, French surgeon Paul Georges Dieulafoy described this condition in his paper, "Exulceratio simplex: Leçons 1-3", but the first case was, in fact, described by Gallard in 1884. In 1988, McClave et al identified the first duodenal Dieulafoy lesion in 4 patients managed surgically. In the same year, Hachisu first reported the successful treatment of gastric Dieulafoy lesion by clipping the lesion with hemoclips.

Dieulafoy lesion is an uncommon condition, accounting for 1-5% of all cases of acute gastrointestinal bleeding in adults (depending on the series). In approximately 4-9% of cases of massive upper gastrointestinal hemorrhage, no demonstrable cause can be found; Dieulafoy lesion is thought to be the cause of acute and chronic upper gastrointestinal bleeding in approximately 1-2% of these cases. It is a well-recognized cause of recurrent, intermittent, and life-threatening bleeding from the gastrointestinal tract, and it results from the rupture of an unexposed submucosal artery.
In a Dieulafoy lesion, the submucosal artery does not undergo normal ramification into mucosal capillary microvessels. Instead, a caliber-persistent artery at the muscularis mucosae is seen. It is characterized by subintimal fibrosis of the artery and an absence of inflammation at the edge of the mucosal defect. As a result, the caliber of the artery is in the range of 1-5 mm. This is approximately 10 times the normal caliber of mucosal capillaries. Previous descriptions of Dieulafoy lesions emphasized a predilection for the proximal stomach at 6 cm from the gastroesophageal junction, most often located along the lesser curvature (80-85% of cases); however, it has been found in all areas of the gastrointestinal tract, including the colon and rectum (10%), esophagus (2%), and small intestine (2%).
The etiology of Dieulafoy lesions is unknown. It was originally thought that Dieulafoy lesions were caused by an aneurysm in one of the vessels within the gastric wall, perhaps in combination with atherosclerosis. It has also been suggested that a congenital or acquired vascular malformation might be the underlying cause. The consensus, however, seems to be that it is caused by an abnormally large-caliber persistent tortuous submucosal artery.
Events that can trigger bleeding are also not well understood. Patients who bleed from Dieulafoy lesions are typically men (the male-to-female ratio is 2:1) who have multiple comorbidities, including cardiovascular disease, hypertension, chronic kidney disease, and diabetes. In the setting of gastrointestinal bleeding caused by Dieulafoy lesions, a history of alcohol abuse or NSAID use is generally absent. The most common presenting symptom is recurrent hematemesis with melena, which is present in 51% of cases; hematemesis without melena is present in 28% of cases, and melena alone is seen in 18%. Patients with lesions in the middle or distal jejunum, right colon, left colon, and rectum may present with only hematochezia in 3% of cases. Bleeding is often self-limited, although it is usually recurrent and can be profuse. Because of the small size of the lesion and the normal surrounding mucosa, the diagnosis of a Dieulafoy lesion can be made with confidence just after or during active bleeding in an area without an associated ulcer or mass lesion. An initial evaluation may reveal hemodynamic instability, postural hypotension, and profound anemia.
A variety of radiologic (eg, small bowel enteroclysis, tagged red blood cell scan, mesenteric angiography) and endoscopic modalities (eg, upper endoscopy, colonoscopy, push enteroscopy, single-balloon enteroscopy, double-balloon enteroscopy, and, most recently, capsule endoscopy) have been used to localize the lesion in the gastrointestinal tract. Video capsule endoscopy (VCE, also known as wireless capsule endoscopy) has a diagnostic yield of 60-80% in patients with obscure gastrointestinal bleeding. In head-to-head comparisons, the yield of VCE is superior to that of push enteroscopy, small bowel enteroclysis, and mesenteric angiography. No reliable data currently exists comparing VCE with double-balloon enteroscopy devices.[6,7,10,11]
At the present time, the diagnosis is usually made by endoscopy. Repeat endoscopies are sometimes necessary. Approximately 49% of lesions are identified during the initial endoscopic examination, while 33% require more than 1 endoscopic evaluation (including push, single-balloon enteroscopy, double-balloon enteroscopy, or VCE) for confident identification. The remaining patients require angiographic identification of the Dieulafoy lesions. In some recent series, however, identification of the lesions was more accurate at the initial endoscopic examination, as Dieulafoy lesions were identified in up to 90% and 95 % of cases. This was attributed to the fact that endoscopy was generally performed within the first 2 hours after admission of the patient, allowing recognition of actively bleeding lesions. It might also, however, reflect the increased awareness of the existence of a Dieulafoy lesion and the experience of the endoscopist. The endoscopic appearance of Dieulafoy lesions varies, and it may consist of active arterial spurting, a protruding vessel without active bleeding, and/or fresh adherent clots. The risk of rebleeding after endoscopic therapy ranges from 9% to 40% in various reports. Endoscopic tattooing with India ink injections has been very helpful for locating the lesion for endoscopic retreatment or intraoperative surgical intervention.[4,6,7,8,9]
Endoscopic management has now become the standard approach for the treatment of these lesions. Several modalities, alone or in combination, are used to control the bleeding, including epinephrine or sclerosant agent injection; hemoclip placement; monopolar, bipolar, heater probe, and argon electrocoagulation; and laser photocoagulation. The endoscopic success rates are reported to be as high as 90-95%. Endoscopic Doppler ultrasonography has been used to confirm ablation of a Dieulafoy lesion by documenting the absence of blood flow following injection therapy.[4,8]
Other treatment options include the following:

Surgical intervention is reserved for those cases in which endoscopic treatment is unsuccessful or the patient rebleeds despite endoscopic treatment. Wedge resection is preferred to simple oversewing of the lesion by the surgeon because of high rebleeding rates. A combined endoscopic and laparoscopic approach has been described; this approach allows precise location of the aberrant vessel with intraoperative endoscopy, followed by a limited laparoscopic surgical resection.
Angiography and embolization is another modality that has been reported in patients with active bleeding who are not amenable to endoscopic therapy.

The possibility of identifying patients at risk for developing Dieulafoy lesions is still uncertain. In at least a subset of patients, mucosal injury may unmask caliber-persistent arteries. In other groups of patients, ischemia resulting from decreased perfusion or oxygenation may play a role.
In this case, the patient was treated with hemoclips because of the large caliber of the vessel; 3 hemoclips obliterated the lesion, and no active bleeding was seen after flushing. The patient was discharged on the fourth day after treatment, without any complications. The patient remained well at 2 months posttreatment; her hemoglobin was stable at approximately 10 g/dL (100 g/L), without any signs or symptoms of hemorrhagic diathesis.

موضوع: رد: اجابةcase 8 الخميس أبريل 02, 2009 9:40 pm

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