Dieulafoy’s lesion is a cause of gastrointestinal bleeding secondary to the rupture of a feeding artery brought on by multiple extrinsic or intrinsic factors, which can occur 5cm, distally, from the gastroesophageal junction, the biliary tree, and even at the level of the bronchial wall.1 Classic Dieulafoy’s lesion corresponds to an aberrant submucosal blood vessel that erodes the overlying epithelium, in the absence of a primary ulcer. This occurs because the vessel does not undergo the normal branching within the wall of the stomach, thus its caliber is up to 10-times higher than the normal caliber of the mucosal capillaries (ranging from 1 to 3mm) and protrudes into the lumen, predisposing to spontaneous ruptures.2,3 At present, 75 to 90% of the lesions reported in the current literature are located in the proximal stomach and up to 10% of the remaining lesions can present at the esophagus, small bowel, colon, rectum, anus, and the bronchial tree.4 Esophageal lesions can be a diagnostic challenge, not only because they are rare, their incidence is unknown, and many authors report on them anecdotally, but also because of the anatomic characteristics of the esophagus that makes their visualization difficult.5 A 48-year-old woman diagnosed with rheumatoid arthritis of 21-year progression and recently diagnosed with type 2 diabetes and primary high blood pressure, was taking methotrexate, leflunomide, and etoricoxib, previously with indomethacin/betamethasone/ methocarbamol, hydroxychloroquine, and deflazacort. The patient came to our medical unit, after presenting with hematemesis and melena of 24h progression. At the emergency room, her vital signs were: heart rate 90bpm, respiratory rate 16 breaths per minute, blood pressure 110/70 mmHg, pulse oximetry 96%, and temperature 36.4°C. Initial laboratory test results were: hemoglobin 13.37g/dl, platelets 259,000cells/mcl, leukocytes 7,500cells/mcl, INR 1.0, activated thromboplastin time 27s, glucose 423 mg/dl, creatinine 0.77mg/dl, blood urea nitrogen 19mg/dl, AST 20 U/l, ALT 34 U/l, LDH 195 U/l, GGT 42 U/l, lipase 45 U/l; venous gasometry with pH 7.37, CO2 40mmHg, O2 35mmHg, and HCO3 24mEq/l. Later, during her hospital stay, the patient had 3 episodes of melena associated with a decrease in hemoglobin of 2.9g/dl and signs of low blood pressure. Upper GI endoscopy revealed a visible vessel in the esophagus 32cm from the upper dental arcade (UDA) that merited band ligation (Fig. 1a and b) and showed an 8 mm ulcer at the gastroesophageal junction (34cm from the UDA), with a fibrin base and no visible vessel. Esophageal Dieulafoy’s lesion and a Forrest III ulcer at the gastroesophageal junction were diagnosed.

Figure 1.

Upper GI endoscopy. A): Visualization of the vessel 32cm from the superior dentate arcade. B): Successful ligation of the visible esophageal vessel.

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At the end of the procedure, the patient’s hemodynamic status continued to be monitored, with no eventualities, and 20mg of oral levo-pantoprazole every 12h was started. The patient was discharged 48h later, continuing with levo-pantoprazole and 60mg of domperidone every 24h. Three months after her discharge, there was no new evidence of bleeding at the gastroenterology control follow-up appointment, and so the patient was definitively discharged.

As stated above, esophageal Dieulafoy’s lesion is exceptional, and as a result, experience with its approach is minimal. Soetikno et al. reported the first case of Dieulafoy’s lesion treated with band ligation.6 Guerrero-Garcia et al. described the case of a woman in the seventh decade of life who presented with Dieulafoy’s lesion. She was initially treated with an injection of 6cm3 of adrenaline at a 1:10.000 dilution, followed by the application of 2 Hemoclips®. Those authors emphasized the difficulty in initially visualizing the lesion, as well as the potential risk for perforation with the adrenaline/clip technique.4 Inayat et al. published a case series on 3 patients with esophageal Dieulafoy’s lesion, all of whom were treated with Hemoclips®, with no new bleeding evidence at follow-up.7 After Soetikno’s article was published, another report of a case of esophageal Dieulafoy’s lesion appeared, in which the patient was treated with band ligation, after presenting with two episodes of rebleeding following the use of adrenaline and clips.8 Band ligation could be a safe alternative for treating this uncommon disease, based on the existing evidence from its use in other anatomic presentations of Dieulafoy’s lesion.9