A Clinical Study Of Endoscopic Band Ligation In The Treatment Of Hemorrhage Due To Dieulafoy Lesions In The Upper Gastrointestinal Tract

Background and aimsDieulafoy's lesion is an unusual and potentially life-threatening cause of massive upper gastrointestinal(GI)hemorrhage.Endoscopic band ligation(EBL)was considered to be the significant therapeutic tool of esophageal variceal bleeding.This method has rencnetly gained more and more popularity and is becoming the alternative treatment method in the treatment of nonvariceal GI hemorrhage.The aim of this study was to evaluate the efficacy and safety of endoscopic band ligation in the treatment of hemorrhage due to Dieulafoy's lesion,and to investigate the clinical and endoscopic features of Dieulafoy's lesion in the upper gastrointestinal tract.MethodsThirty-seven patients with bleeding Dieulafoy's lesions were prospectively enrolled and were randomly assigned to undergo endoscopic band ligation(EBL)or endoscopic injection sclerosis(EIS), 21 patients in EBL group and 16 patients in EIS group.With the multishot ligation device in EBL group,suction was applied,drawed the Dieulafoy's lesion and the surrounding mucosa into the lumen of the ligator,then the preloaded elastic band was fired and the Dieulafoy's lesion was ligated by it.Endoscopic injection hemostasis with 5%sodium morrhuate or 1%aethoxysklerol was performed around or focusing on Dieulafoy's lesion in EIS group.The clinic and endoscopic features of EBL group and EIS group were collected and analyzed retrospectively, and the effectiveness of these two groups were also compared.Results1.Clinical featuresThis study group of 37 patients with bleeding Dieulafoy's lesion in upper gastrointestinal tract,consisted of 30 male and 7 female patients (male:female=4.3:1),with a mean age of 52.7 years(ranged from 15to77 years).The history of chronic diseases(such as hypertension and diabetes et al)was coexisted in 17 patients(45.9%),and the utilization of low dose aspirin or non-steroidal anti-inflammatory drugs(NSAID),the history of ingestion alcohol with several extents were presented in 14 patients (37.8%).Accidental and intermittence hematemesis and melena were the leading symptoms of Dieulafoy's lesion.There were 28 patients(75.7%) admitted for hematemesis accompanied with melena,6 patients(16.2%) for hematemesis merely,3 patients(8.1%)for melena merely,and 14 patients(37.8%)in the group accompanied with hemorrhagic shock.2.Location of lesionAmong the bleeding Dieulafoy's lesion in upper gastrointestinal tract of the 37 patients,Dieulafoy's lesion was located in the stomach in 23 patients(62.2%),in the gastrointestinal anastomotic stoma in 9 patients(24.3%),in the duodenum in 4 patients(10.8%),in the esophagus in 1 patient(2.7%).The lesion occurred within 6cm of the esophagogastric junction was presented in 51.4%of the cases(19/37), and occurred in gastrointestinal anastomotic stoma after subtotal gastrectomy was presented in 24.3%of the cases(9/37).These prompted that Dieulafoy's lesion is most commonly located in proximal stomach, especaily within 6cm of the esophagogastric junction,and it can be identified that the secondary commonly location was gastrointestinal anastomotic stoma after subtotal gastrectomy.3.Endoscopic featuresThere were Dieulafoy's lesion presenting an isolated minute round or elliptical mucosal defect in 33 cases(89.2%).The size of it ranged from 2 to 3 ram,with sharpness of border.There were visualization of a protruding arteriole in the middle of the defect,with adherent clot or errhysis on the naked vessel,or with active impulsivity spurting,without significant inflammation surrounding mucosa;Lesions presenting isolated coni-like polypoid changes counted to 5.4%(2/37),active arterial spurting bleeding from normal mucosa counted to 2.7%(1/37),fresh adherent punctiform clot on normal mucosa counted to 2.7%(1/37).4.Results of endoscopic diagnosisAmong the 37 patients with bleeding Dieulafoy's lesion in upper gastrointestinal tract,there were lesions appeared typically in 35 patients, lesions appeared non-typically and coni-like polypoid in 2 patients.The diagnostic puncture with injection needles of sclerosant was applied to final diagnosis.5.Effectiveness of EBL and EIS groups after endoscopic treatment.The average employment of elastic band was 1 piece(1-2 pieces in standard)per case in EBL group.And 3.9ml(3.0-5.0ml in standard)of sclerosant was requirement per case in the EIS group averagely.The tissue ligated fallen off in three days to seven days after treatment of EBL. A round or elliptical ulcer formed on local mucosa after operation,the diameter of the ulcer in EBL group were significantly less than that in EIS group(8.3±1.0mm vs 13.8±3.2mm respectively,p＜0.005);The rates of initial hemostasis,permanent hemostasis and transfer into surgery in EBL group were similar to those in EIS group(95.2%vs 87.5%,100%vs 87.5%and 0 vs 12.5%respectively,P＞0.05),but the rate of rebleeding in EBL group were significantly lower than that in EIS group(4.8%vs 37.5%respectively,P＜0.05),There was no statistically significant differences in rates of complications and mortality between these two groups(4.8%vs 6.3%,0 vs 0 respectively,P＞0.05).Conclusions1.Dieulafoy's lesion in upper gastrointestinal tract was one of causes of massive upper gastrointestional hemorrhage,it was more commonly in males than in females,with the wide range of age but more frequently in those above 50 years old2.These following factors were considered possiblely to induce,or aggravate the final rupture of the vessel in Dieulafoy's lesion in upper GI tract,such as hypertension,diabetes,chronic renal failure,using of causticity drugs,ingestion alcohol and some other chronic diseases.3.Dieulafoy's lesion in upper GI tract took the accidental and intermittence hematemesis and melena to be the main cinlical features, and usually with hemorrhagic shock.4.Dieulafoy's lesion was most commonly located in the proximal stomach,especially within 6cm of the esophagogastric junction.The secondary common location was gastrointestinal anastomotic stoma after subtotal gastrectomy.Dieulafoy's lesion could be not only an congenital disease,but also an gained disease after birth.5.The most commonly appearance of Dieulafoy's lesion was a minute round or elliptical mucosal defect.The size of it ranged from 2 to 3 mm,with sharpness of border.There were visualization of a protruding arteriole in the middle of defect,with adherent clot or errhysis on the naked vessel,or with active impulsivity spurting,without significant inflammation surrounding mucosa,6.Without any other effective diagnosis method,while preparing for endoscopic treatment,it was an effective and simple method to progress diagnostic puncture to non-typically lesions. 7.Comparing the hemostasis effectiveness of Dieulafoy's lesion after endoscopic treatment,that in EBL group was similar to it in EIS group,but the rate of rebleeding was significantly lower than that in EIS group.Therefore,endoscopic band ligation was an ideal endoscopic treatment of bleeding Dieulafoy's disease in upper GI hemerrhage.