Challenges in Diagnosing and Managing Dieulafoy’s Lesions: A Case Report Highlighting the Importance of Clinical Suspicion and Multidisciplinary Approach in Obscure Gastrointestinal Bleeding

Upper gastrointestinal bleeding remains a significant cause of hospital admissions. Even though the incidence of peptic ulcer disease and gastritis is decreasing, the incidence rates in neoplasm, Dieulafoy’s lesions, angiodysplasia, and esophagitis are trending up, which necessities physicians to be aware of those pathologies and their specifics. Here, we represent a case of a 62-year-old male on dual antiplatelet therapy who was transferred to our hospital due to severe melena with suspicion of upper gastrointestinal bleeding. Due to hemodynamic instability, the patient was intubated and started on vasopressors. However, several repeated EGDs and CTs of the abdomen with GI bleeding protocol did not reveal the location of active bleeding to stop it. At the same time, clinically, the patient was hemodynamically unstable with continued melena. On the last EGD, a small area of concern resembling gastric varix was clipped for identification purposes, and the patient underwent a selective angiogram with further diagnosis of Dieulafoy’s lesion, which was successfully embolized. Our case demonstrates that Dieulafoy’s lesions can present as severe life-threatening hemorrhage, hard to diagnose with traditional methods such as EGD or CTs, in which case it is recommended to proceed with an angiogram sooner rather than later for further diagnosis and treatment if needed.

Uremic Bleeding in 2 Patients with Dieulafoy’s Lesion: Case Report and Literature Review

Dieulafoy’s lesions are rare vascular malformations of the gastrointestinal tract. A Dieulafoy’s lesion is an aberrant vessel that does not reduce in caliber when it extends from the submucosa to the mucosa. Damage to this artery can cause severe and intermittent arterial bleeding from small vascular stumps that are difficult to visualize. Furthermore, these catastrophic bleeding episodes frequently result in hemodynamic instability and the need for transfusion of multiple blood products. Recently, uremic syndrome has been identified as a risk factor for gastric mucosal lesions. We present two clinical cases of acute digestive bleeding due to Dielafoy lesion with chronic kidney disease as the main cause, where two different therapies were performed endoscopically. We concluded with the results of our patients that the best therapy was the application of the hemostatic hemoclip on the injury vs the injection with adrenaline on the wound site. Uremia is identified as a risk factor for upper gastrointestinal bleeding in patients with pre-existing Dieulafoy’s lesion, as well as a higher incidence of new bleeding.

An Infant with Dieulafoy’s Lesion: A Case Report from the Philippines

This is a case of a 5-month-old infant who experienced repeated episodes of hematemesis and no known underlying health conditions. It was subsequently diagnosed as Dieulafoy’s lesion localized in the lesser curvature of the stomach. Endoscopic diagnosis and treatment were done by angiographic embolization. Dieulafoy’s lesion is considered rare even for adult cases, much more for pediatric patients and usually underdiagnosed. Hence, patients presenting with gastrointestinal bleeding should be managed in a multidisciplinary approach. Spreading awareness about this lesion by including it in the considerations, may help improve early detection and treatment.

Nora's病一例

Nora’s病又称奇异性骨旁骨软骨瘤性增生（Bizarre parosteal osteochondromatous proliferation，BPOP），是一种罕见的良性骨膜外骨软骨瘤样增生性病变。1983年Nora等首先描述了35例发生于足部的奇异性骨旁骨软骨瘤性增生，因此命名为Nora’s病或Nora’s病损。目前国内报道很少。我科于2013年2月收治一例，现报道如下：

Florid reactive periostitis ossificans of the humerus: Case report and differential diagnosis of periosteal lesions of long bones

A case of florid reactive periostitis ossificans(RPO) arising in a long bone is presented. This is a rare bone proliferation with a pronounced periosteal reaction. Less than 100 cases have been described in the literature with far fewer outside the bones of the hand, feet, fingers, and toes. Although the etiology is unknown, a relationship to preceding trauma is suggested. The imaging and histologic features show an overlap with other bone lesions including bizarre parosteal osteochondromatous proliferation, subungual exostosis, and malignant surface tumors of bone and cartilage which include, periosteal and parosteal osteosarcoma. It is important to recognize the clinical presentation and diagnostic features of RPO as a benign entity so that it is not mistaken for a more aggressive neoplasm. We present a case of a right distal humeral lesion that on histopathological review revealed florid RPO. This diagnosis was not suspected on imaging studies, but was made on open biopsy of the mass. The patient remains disease free, years postoperatively. In addition to presenting this unique case report, we review the pertinent literature, and offer a differential diagnosis and treatment strategy for its management.

Clinical and endoscopic analysis of gastric Dieulafoy’s lesion

AIM:To investigate the incidence,location,clinical presentation,diagnosis and effectiveness of endoscopic treatment of gastric Dieulafoy's lesion(DL)in China. METHODS:All patients who received emergency upper gastrointestinal(GI)endoscopy due to gastric DL from February 2000 to August 2008 at GI endoscopy center of Renmin Hospital of Wuhan University were included in this study.The clinical presentation,medical history,location and characteristics of DL methods and effectiveness of therapy of patients with DL were retrospectively analysed by chart reviews.Long-term follow-up data were collected at outpatient clinics or telephone interviews. RESULTS:Fifteen patients were diagnosized with DL,which account for 1.04%of the source of bleed- ing in acute non-variceal upper GI bleeding.Common comorbidities were found in one patient with hypertension and diabetic mellitus.Hemoclip or combined therapy with hemoclip produced primary hemostasis in 92.8%(13/14) of patients. CONCLUSION:DL is uncommon but life-threatening in China.Hemoclip proved to be safe and effective in controlling bleeding from DL.

Mini-loop ligation of a bleeding duodenal Dieulafoy's lesion

Two percent of gastrointestinal hemorrhages are caused by Dieulafoy's lesions, which are located in duodenum in only 15% of cases. There are no recommendations regarding the prime endoscopic treatment technique for this condition. A 61-year-old woman presented with melena without signs of hemodynamic instability. During an urgent upper endoscopy, blood oozing from the normal mucosa of the duodenum was seen and this was classified as a Dieulafoy's lesion. A mini-loop was opened at the rim of a transparent ligation chamber, at the end of the endoscope, and after aspiration of the lesion, closed and detached. Complete hemostasis was achieved without early or postponed complications. In every day clinical practice, mini-loop ligation is rarely used because of possible complications, such as site ulceration, organ perforation, re-bleeding and possible inexperience of the operator. To the best of our knowledge this is the first case of successful treatment of bleeding duodenal Dieulafoy's lesion by mini-loop ligation.

Endoscopic management of Dieulafoy's lesion using Isoamyl-2-cyanoacrylate

Dieulafoy's lesion (DL) is a rare but important cause of obscure gastrointestinal bleeding that may be over-looked during diagnostic endoscopy. Mortality rates are similar to those of other causes for gastrointestinal bleeding. Diagnosis by upper endoscopy is the modal-ity of choice during acute bleeding. In the absence of active bleeding, the lesion resembles a raised nipple or visible vessel. There are no guidelines regarding effective selective therapy for DL, when diagnosed, en-doscopist experience is the major determinant of the treatment strategy. Following our strategy, an expert endoscopist with a skilled assistant should have a high rate of successful DL diagnosis when an obscured gas-trointestinal lesion is suspected. Cyanoacryltes com-pounds have been used successfully in management of Gastric varices and DLs. To our knowledge, there have been no previous reports regarding use of isoamyl-2-cyanoacrylate (AMCRYLATE ; Concord Drugs Ltd.,Hyderabad, India) as an effective therapy for gastric DL without serious complications. In our case study, Isoamyl-2-cyanoacrylate (AMCRYLATE) was effective and safe for treating DL. Surgical wedge resection of the lesion should be considered as a therapeutic option if endoscopic therapy fails.

S100 PROTEIN-POSITIVE DENDRITIC CELLS AND THE SIGNIFICANCE OF THEIR DENSITY IN GASTRIC PRECANCEROUS LESIONS

Quantitative analysis of dendritic cells (DC’s) was carried out in tissue specimens of normalgastric mucosa (n=15),gastric ulcer (n=19),chronic atrophic gastritis (n=28),and gastriccarcinoma (n=65) by ABC immunostaining with S100 protein antibody.Significant increasein DC number were observed in chronic atrophic gastritis with type Ⅲ intestinal metaplasiaand/or grade Ⅱ,Ⅲ dysplasia.The result suggests that DC’s are potentially capable opresenting neoantigens associated with malignant transformation at the precancerous stagewhen malignant morphological changes have not yet taken place.Combined with routinediagnostic methods,the serial monitoring of DC density in gastric mucosa may be usefulin the follow-up of premalignant lesions in the stomach and the diagnosis of early gastriccarcinoma.

Bizarre Parosteal Osteochondromatous Proliferation-Like Lesion Originating in Soft Tissue: Report of a Case

Many tumors are unique to the organs from which they arise. Over the last 20 years, however, most tumors that were thought to be primary in soft tissues (derived from the primitive mesenchyme) and thought not to have counterparts in bone, were found to, in fact, rarely arise as unique lesions from bone. Some examples include synovial sarcoma, rhabdomyosarcoma and leiomyosarcoma, to name but three. We now have begun to see the reverse with lesions that were initially thought to be unique to bone arising in soft tissue. While this has been well reported with osteosarcoma and Ewing's sarcoma, it has never been reported with Bizarre Parosteal Osteochondromatous Proliferation (BPOP), also known as Nora's lesion. This study explores the first reported case of a soft tissue lesion, with clinical, radiological and histopathological characteristics of BPOP.

Bleeding Dieulafoy's-like lesions of the gut identified by capsule endoscopy

Dieulafoy's-like lesions (DLs-like) represent a cause of obscure gastrointestinal bleeding, enteroscopy being the main diagnostic and therapeutic procedure. Frequently, more than one enteroscopy is needed to identify the bleeding vessel. In our practice, video capsule endoscopy (VCE) identified and guided therapy in four cases of DLs-like; three of them were localized on the small bowel. We report, for the first time, a diagnosis of colonic DL-like performed by colon capsule endoscopy. Two patients presented with severe cardiovascular disorders, being hemodynamically unstable during VCE examination. Based on the VCE findings, only one invasive therapeutic procedure per patient was necessary to achieve hemostasis. VCE and enteroscopy may be regarded as complementary procedures in patients with gut DLs-like.

Endoscopic lysis of bladder scar associated with Hunner’s lesions:A new technique

Objective:Five to ten percent of interstitial cystitis/bladder pain syndrome(IC/BPS)patients have Hunner’s lesions(HL),areas of non-specific inflammation and scarring.The poor quality of life of patients with HL is entwined in associated pain and loss of bladder capacity.Although the decrease in bladder capacity is usually dependent on pain,it may also be dependent upon scarring and associated compliance changes produced by the inflammatory process.This report reviews the potential role of endoscopic scar lysis using the holmium laser in the management of these patients whose only other therapeutic option is urinary diversion.Methods:Two patients with HL and“end stage”bladders who underwent holmium laser division of bladder wall scar/tethering were identified.Clinical data were reviewed with emphasis on safety and efficacy.Results:Both patients selected for this procedure underwent holmium laser lysis of known scar tissue in an effort to increase bladder capacity and improve symptoms of urinary frequency and pain with bladder filling.The median age of patients who underwent the procedure was 63(59-67)years.Incisions were made with the holmium laser at frequencies of 3e10 Hz of 300e700 J along the region of scarring.All procedures were performed by the same practitioner.There was an increase in bladder capacity by 58.3%(50.0%-66.7%).During a mean follow-up of 4.2 years,there appeared to be a significant improvement with an increase in interval time between voids and a decrease in pain with bladder filling.Conclusion:Patients with IC/BPS may be severely debilitated by a clinically significant decrease in their bladder capacity,especially in the face of HL.The use of the holmium laser to incise regions of scar and bladder wall tethering may produce a clinically significant and durable increase in bladder capacity.The use of this technique as a means of treating bladder scarring poses an excellent adjunct to existing treatment strategies.

Evaluation in vinyl chloride monomer-exposed workers and the relationship between liver lesions and gene polymorphisms of metabolic enzymes

AIM: To analyze occupational health hazards exposure to doses lower than the Chinese occupational health standard in a selected VC polymerization plant in China,and also to elucidate the relationship between genetic polymorphisms and genetic susceptibility on liver lesions of workers exposed to vinyl chloride monomer (VCM).METHODS: In order to explore the mechanism of VCM-related health effects, we used a case-control design to investigate the association between the genetic polymorphisms of metabolic enzymes and liver lesions in workers occupationally exposed to VCM. Genotypes of CYP2E1, GSTT1, GSTM1, ALDH2 and ADH2 were identified using PCR and PCR-RFLP.RESULTS: Even when the concentration of VCM was lower than the current Chinese occupational health standard,neurasthenia, pharyngeal irritation, liver ultrasonography abnormalities and hemoglobin disorders were significantly higher in exposure subjects compared to non-exposure subjects, and the relative risks (RR and 95% CI) were 1.74 (1.06-2.85), 1.97 (1.56-2.48), 10.69 (4.38-26.12),and 2.07 (1.20-3.57). CYP2E1 c1c2/c2c2 genotype was significantly associated with liver damages (OR 3.29, 95% CI 1.51-7.20, P＜0.01).CONCLUSION: The incidences of neurasthenia and liver ultrasonography abnormalities significantly increase when the cumulative exposure dose increases. The genotypes of metabolic enzymes (CYP2E1 c1c2/c2c2, null GSTT1 and ADH2 1-1) play important roles in VCM metabolism.Polymorphisms of CYP 2E1, GSTT1 and ADH2 may be a major reason of genetic susceptibility in VCM-induced hepatic damage.

Oncogenic Role of Skp2 and p27^(Kip1) in Intraductal Proliferative Lesions of the Breast

Objective To investigate whether the connection of p27 Kip1 to S-phase kinase-associated protein 2 (Skp2) plays an oncogenic role in intraductal proliferative lesions of the breast. Methods Here we investigated the mechanism involved in association of Skp2's degradation of p27 Kip1 with the breast carcinogenesis by immunohistochemical method through detection of Skp2 and p27 Kip1 protein levels in 120 paraffin-embedded tissues of intraductal proliferative lesions including usual ductal hyperplasia (UDH, n=30), atypical ductal hyperplasia (n=30), flat epithelial atypia (FEA, n=30), and ductal carcinoma in situ (DCIS, n=30). Moreover, the expression status of Skp2 and p27 Kip1 in 30 cases of the normal breast paraffin-embedded tissues were explored. Results The DCIS group was with the highest Skp2 level and the lowest p27 Kip1 level, and the UDH group was with the lowest Skp2 level and the highest p27 Kip1 level. Both Skp2 and p27 Kip1 levels in the DCIS group were significantly different from those in the UDH group (all P<0.01). The levels of Skp2 and p27 Kip1 in the FEA group were significantly different from both the DCIS and UDH groups (all P<0.05). p27 Kip1 was negatively correlated with Skp2 in both the UDH group (r=-0.629, P=0.026) and DCIS group (r=-0.893, P=0.000). Conclusion Overexpression of Skp2 might be the mechanism underlying p27 Kip1 over degradation.

Elaboration and validation of Crohn's disease anoperineal lesions consensual definitions

AIM To establish consensual definitions of anoperineal lesions of Crohn's(APLOC) disease and assess interobserver agreement on their diagnosis between experts.METHODS A database of digitally recorded pictures of APLOC was examined by a coordinating group who selected two series of 20 pictures illustrating the various aspects of APLOC. A reading group comprised: eight experts from the Société Nationale Fran?aise de Colo Proctologie group of study and research in proctology and one academic dermatologist. All members of the coordinating and reading groups participated in dedicated meetings. The coordinating group initially conducted a literature review to analyse verbatim descriptions used to evaluate APLOC. The study included two phases: establishment of consensual definitions using a formal consensus method and later assessment of interobserver agreement on the diagnosis of APLOC using photos of APLOC, a standardised questionnaire and Fleiss' s kappa test or descriptive statistics.RESULTS Terms used in literature to evaluate visible APLOC did not include precise definitions or reference to definitions. Most of the expert reports on the first set of photos agreed with the main diagnosis but their verbatim reporting contained substantial variation. The definitions of ulceration(entity, depth, extension), anal skin tags(entity, inflammatory activity, ulcerated aspect), fistula(complexity, quality of drainage, inflammatory activity of external openings), perianal skin lesions(abscess, papules, edema, erythema) and anoperineal scars were validated. For fistulae, they decided to follow the American Gastroenterology Association's guidelines definitions. The diagnosis of ulceration(κ = 0.70), fistulae(κ = 0.75), inflammatory activity of external fistula openings(86.6% agreement), a b s c e s s e s( 8 4. 6 % a g r e e m e n t) a n d e r y t h e m a(100% agreement) achieved a substantial degree of interobserver reproducibility. CONCLUSION This study constructed consensual definitions of APLOC and their characteristics and showed that experts have a fair level of interobserver agreement when using most of the definitions.

Culprit for recurrent acute gastrointestinal massive bleeding: “Small bowel Dieulafoy's lesions”-a case report and literature review

A Dieulafoy's lesion is a dilated,aberrant,submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion.It can be located anywhere in the gastrointestinal tract.We describe a case of massive gastrointestinal bleeding from Dieulafoy's lesions in the duodenum.Etiology and precipitating events of a Dieulafoy's lesion are not well known.Bleeding can range from being self-limited to massive life- threatening.Endoscopic hemostasis can be achieved with a combination of therapeutic modalities.The endoscopic management includes sclerosant injection,heater probe,laser therapy,electrocautery,cyanoacrylate glue,banding,and clipping.Endoscopic tattooing can be helpful to locate the lesion for further endoscopic re-treatment or intraoperative wedge resection.Therapeutic options for re-bleeding lesions comprise of repeated endoscopic hemostasis,angiographic embolization or surgical wedge resection of the lesions.We present a 63-yearold Caucasian male with active bleeding from the two small bowel Dieulafoy's lesions,which was successfully controlled with epinephrine injection and clip applications.

Angiodysplasia Presenting with Multiple Polypoid Lesions: An Unusual Cause of Small Bowel Obstruction

Angiodysplasia (AD), a morphologic vascular abnormality, is a common cause of gastrointestinal bleeding. We present a rare case of polypoid AD lesions. Three years after treatment for adhesive bowel obstruction, a 57-year-old man was admitted with recurrent abdominal distension, anorexia, and lower extremity edema. Computed tomography showed his dilated proximal and collapsed distal small bowel loops had disparate calibers. The transition point demonstrated mucosal enhancement and mesenteric lymphadenopathy. We observed small intestinal wall outpouching with strong mucosal enhancement and polypoid lesions dotting the dilated intestine. Intraoperative findings revealed a hard but elastic intraluminal nodule causing small bowel obstruction and the outpouching’s occurrence on the ileum’s antimesenteric border. We performed partial resection of the small intestine involving the nodule and Meckel’s diverticulum. Macroscopically, the nodule, diverticulum, and intestinal mucosa had polypoid lesions. Histopathologically, these lesions had foci within dilated thin- or thick-walled vascular channels in the submucosa, without specific histological abnormalities. These features led to a diagnosis of AD.

Bowen’s disease with multiple lesions of the penis and scrotum:A case report

Bowen’s disease is a rare squamous cell carcinoma in situ of the skin,the etiology and pathogenesis of which remain unclear.A 57-year-old man presented with the penis and scrotum erythema,with indistinct boundaries with the surrounding tissue.Pathology and histopathology of the biopsy specimen revealed Bowen’s disease.There are many clinical treatments for Bowen’s disease,including surgical excision,liquid nitrogen freezing,electrocautery,laser therapy,topical application of 5-fluorouracil ointment,and photodynamic therapy.Bowen’s disease mostly involves solitary lesions.This case involved multiple lesions,and its scope was extensive;therefore,surgical resection was performed.

Awakening of Nora—On Ibsen’s A Doll’s House

A doll’s house tells us a story of a woman,who is treated as a doll-child by her father,then a doll-wife by her husband,eventually realizes her subordinate role at home,so she resolutely leaves the apparently perfect marriage and tries to seek out her own individuality.It questions the entire fabric of marital relationships,and indicts all the false values of the masculine society.

Dieulafoy’s Lesion of the Duodenum: The Management of This Unusual Location

Dieulafoy lesion (DL) is a rare source of gastrointestinal tract bleeding that can affect any site of the gastrointestinal tract, particularly the stomach and less commonly the duodenum. Early endoscopy during a bleeding episode is essential for an accurate diagnosis and sometimes multiple endoscopies are needed to establish the diagnosis. In this report, we describe a case of duodenal DL detected and treated by endoscopy. We report the case of a 65-year-old patient admitted for massive upper gastrointestinal bleeding due to a Dieulafoy lesion of the duodenum. Endoscopic diagnosis and treatment were possible and hemostasis was achieved by injecting adrenaline and placing 3 clips. Various effective endoscopic techniques are available to control bleeding, the combination of injection therapy and mechanical therapy reduces the risk of recurrence.