Specially located peptic ulcers (Dieulafoy's disease), also known as Dieulafoy's lesion, are a common cause of peptic ulcers, which are caused by a variety of diseases. 's lesion), is one of the causes of hemorrhage in the gastrointestinal tract, especially in the upper gastrointestinal tract. So far there is no precise definition, the lesion is exposed in the gastrointestinal lumen of the active bleeding or adherent clots in the arteries, arterial periphery without ulcer formation has become the majority of scholars *** understanding of this feature. Specifically located peptic ulcers can occur in any part of the gastrointestinal tract, with the proximal stomach being the most common.In 1898, Dieulafoy first reported three cases of death due to rupture of the gastric artery resulting in upper gastrointestinal haemorrhage, and concluded that the lesion was a superficial ulcer of the gastric mucosa causing rupture of the gastric artery, and that the hemorrhage had interrupted the further development of the lesion. Since then, Dieulafoy's name has been associated with bleeding from rupture of the submucosal artery of the stomach. In the early days, due to the lack of in-depth study of the pathological nature of the disease, the names used in the literature varied, such as Dieulafoy vascular malformation, Dieulafoy gastric mucosal erosion, superficial ulcer, rupture and bleeding of the gastric submucosal artery of constant diameter, gastric submucosal arteriosclerosis, submucosal arterial malformation, varicose arterial aneurysm, gastric arterial aneurysm, arteriovenous malformation, and Dieulafoy's disease, etc. In 1988. Saueraber reported 7 patients and elucidated the pathogenesis, pathology, clinical features, diagnosis and treatment of the disease in detail through literature review. In recent years, due to the widespread use of endoscopy, the disease has been increasingly reported and unified called peptic ulcer in special locations.
2 Name of the diseaseSpecial location of peptic ulcer
3 Name of the diseaseDieulafoy disease
4 Alias of special location of peptic ulcerDieulafoy disease; Dieulafoy lesion; Dieulafoy gastric mucosal erosion; Dieulafoy vascular malformation; arteriovenous malformation; Arteriovenous vascular malformation; submucosal arteriovenous malformation; superficial ulcer; varicose aneurysm; Dieulafoy's disease; gastric aneurysm; gastric submucosal arteriosclerosis; rupture and bleeding of submucosal arteries of the constant diameter of the stomach
5 ClassificationGastroenterology > Gastroduodenal disorders > Other disorders of the stomach
6 ICD number
K31.8
7 Epidemiologyp> Peptic ulcers in special locations are relatively rare, accounting for 0.3% to 6.8% of cases of upper gastrointestinal hemorrhage in developed Western countries, and 1.1% to 9.4% in Japan, with an average age of 33.7 years in the seven cases reported by Dieulafoy, and a male-to-female ratio of 1.3:1, which is roughly equal. In recent years, Tanaka collected 93 cases in Japan, with an average age of 53.9 years and a male-to-female ratio of 3.2:1, with more men. The United States Norton et al. reported 1 group of 89 cases, the average age of 72 years old, suggesting that advanced age is more common. Morbidity and mortality rate 6 deaths in 7 cases reported by Dieulafoy in 1898, 19 deaths in 19 cases (79%) in 24 cases reported by Glodmen in 1964, deaths in 8 cases (23%) in 35 cases reported by Zanten et al. from 1970 to 1984, and deaths in 12 cases (13%) in 89 cases reported by Norton et al. in 1999. The morbidity and mortality rates are decreasing over the years for reasons related to the popularity of endoscopy and advances in treatment.
8 EtiologyThe pathogenesis of peptic ulcers in special locations is not completely clear. In the past, peptic ulcers in special locations have been categorized as gastric aneurysms, and it was thought that bleeding was due to expansion and rupture of the aneurysm, but recent pathological examinations have found that the blood vessels in peptic ulcers in special locations have an endothelium, a midlayer, and an epithelium, which ruled out aneurysms, and it has been suggested that peptic ulcers in special locations are congenital arteriovenous malformation, but the presence of arteriovenous malformation was not found in the study. Under normal circumstances, the blood supply of the gastric wall mainly comes from the short gastric artery, the branches of which gradually become thinner after entering the gastric wall and eventually form a capillary system in the gastric mucosa, but the branches of the short gastric artery in patients with peptic ulcers in special locations maintain a constant diameter after entering the muscular layer of the gastric mucosa, and are thus called constant diameter arteries. It is generally believed that the constant diameter artery is a congenital developmental abnormality, and there is a special relationship between the constant diameter artery and the mucosa. Under normal circumstances, the loose tissue under the mucosa allows the mucosa on the surface of the artery to move freely, but in patients with peptic ulcers in special locations, because of the fixation of the arteries and the mucosa by the Wanken fiber bundles, the formation of a specific area of vulnerability to the mucosa, and the relationship of the Wanken fiber bundles with the arteries and the mucosa may be congenital. The relationship between the Wanken fiber bundles and the artery and mucosa may be congenital. Mucosal vulnerable area under external factors ***, mucosal injury and cause the rupture of submucosal constant diameter arteries; with age, the arterial diameter dilation, mucosal atrophy, this weak environment is more susceptible to damage. Thus, the peptic ulcer foci in specific locations are composed of submucosal arterioles and superficial mucosal erosions. A variety of factors can promote gastric mucosal erosion and constant diameter artery rupture, such as heavy drinking, smoking, bile reflux can cause gastric mucosal erosion; gastric peristalsis constant diameter artery pressure, elongation, peristalsis generated by the cutting force or mechanical damage can also be caused by rupture of blood vessels. Constant diameter artery is not a sudden corrosion rupture, but due to the wall gradually thinning, expansion and rupture, rupture is often preceded by thrombus formation. Some studies have found that the special location of peptic ulcer foci of blood vessels with varying degrees of atherosclerosis, the hardening of blood vessels is more likely to rupture, this phenomenon can be explained by the age of onset of peptic ulcers in special locations.
9 PathogenesisThe histopathology of peptic ulcers in special locations has two typical features: small foci, mostly 2-5 mm ovoid superficial erosion, can reach the mucosal muscle layer, in the center of the mucosal foci can be seen in the diameter of 1-3 mm arteries protruding in the part of the mucosal defects, the surface can have thrombus attachment, the mucous membrane around the foci has no inflammatory changes, due to the small foci, easy to ignore during endoscopy; Special location, special location of peptic ulcer foci are often located in the small curvature side of the gastric cardia, Zanten reported that 82% of the foci are located in the esophagus and stomach within 6cm of the connection, 81% of the foci are located in the small curvature side of the stomach, and there are very few foci are located in the duodenum, the jejunum, and the colon and rectum.
The microscopic pathologic features of specially located peptic ulcer lesions are:
1. Superficial focal defects of the gastric mucosa with basal fibrous necrosis.
2. Larger arterioles with thickened walls at the base of the defect; twisted, hyperplastic arterioles in the muscular layer of the mucosa.
3. Thickening of the venous diameters accompanying the arteries of the muscular layer of the mucosa.
The ruptured arterial wall was seen to have a mild inflammatory reaction under high magnification, with fibrous thrombus formation in the lumen, submucosal fibrous deposits in the arterial wall, and thickening of the gastric mucosal muscular layer, with no inflammatory reaction in the mucosa surrounding the lesion. Elastic fiber staining was used and found that the elastic fiber tissue around the wall of the ruptured artery was loosened, and there was no aneurysmal dilatation of the arterial wall and no arteritis (Fig. 1).Miko analyzed the histopathological difference between the bleeding arteries of the peptic ulcer in special location and the normal arteries of 24 cases, and found that the arteries of the bleeding arteries of the peptic ulcer in special location had the normal histological structure, which is composed of the mucous membrane, the muscularis mucosae, and the epimucosal membrane. The diameter of the submucosal artery was normal, the thickening of the vessels was mainly in the mucosal muscular layer, the artery was fixed to the mucosa by Wanken elastic fibers, and there was a mucosal defect at the arterial fissure, with rupture of the accompanying vein.
10 Clinical manifestations of specifically located peptic ulcerThe main clinical manifestations of specifically located peptic ulcer are recurrent episodes of blood vomiting and tarry stools, and in severe cases, hemorrhagic shock; there is no obvious epigastric discomfort or pain before bleeding, and there is no history of peptic ulcer or family history of the disease.
11 Complications of specifically located peptic ulcersThe main clinical manifestations of specifically located peptic ulcers are recurrent episodes of vomiting blood and tarry stools, and in severe cases, hemorrhagic shock.
12 Laboratory tests1. Fecal occult blood test may be positive.
2. Blood tests show a decrease in total hemoglobin.
13 Ancillary tests 13.1 EndoscopyThe diagnosis of endoscopy depends on the examiner's knowledge and experience with specifically located peptic ulcers. The endoscopic manifestations of peptic ulcers in special locations are variable (Figure 2), and the main features are: focal defects of gastric mucosa in the cardia region with jet-like bleeding; superficial depression of the gastric mucosa, with blood vessels walking in the middle of the defects and blood clots adhering to the surface; and occasional small blood vessels protruding out of the surface of the normal mucosa with pulsatile bleeding. Endoscopic diagnosis of peptic ulcers in special locations is difficult, with a confirmed diagnosis rate of only 37% reported. In the lesion of active bleeding, a large amount of blood or blood clot in the gastric cavity to cover the bleeding point, endoscopy is difficult to find the lesion; even if the bleeding stops, smaller lesions are easy to ignore.
13.2 Selective angiographyThe diagnostic rate of peptic ulcers in special locations is 20% to 30%, and Burham reported that only 3 of 9 patients who had preoperative selective peritoneal arteriography were diagnosed. The angiographic features of specially located peptic ulcers are: the contrast agent enters the proximal stomach via the left gastric artery, rapidly enters the gastric lumen from the area of mucosal punctate vesicles, and the arterial morphology is normal, with no aneurysm formation or presence of an arteriovenous shunt. However, selective abdominal arteriography must be performed in the presence of active bleeding to successfully indicate the site of bleeding, and if the bleeding stops, the catheter may be considered to be left in the vessel for 24 h. Diagnosis can be expected to be obtained by performing an angiogram as soon as there is bleeding. It is generally believed that patients with peptic ulcers in special locations that remain negative after multiple endoscopies can use selective abdominal arteriography to make a definitive diagnosis.
13.3 Nuclear examinationThe use of 99Tc erythrocyte tracer technology to diagnose specifically located peptic ulcer has been successfully reported. 99Tc erythrocyte examination can help to detect bleeding points when endoscopy and selective abdominal arteriography fail to detect bleeding points.
14 DiagnosisDue to the lack of specificity in the clinical manifestations of peptic ulcers in special locations, endoscopy, selective angiography, nuclear tracing and other tests can help in the preoperative diagnosis of peptic ulcers in special locations and provide an important basis for the surgical treatment, and some of the patients can be diagnosed only when they are dissected and pathologically examined at autopsy.
Intraoperative diagnosis: most peptic ulcers in special locations are diagnosed during emergency surgical exploration, intraoperative exploration of the stomach surface morphology is normal, no peptic ulcer foci or portal hypertensive esophageal varices and other causes of bleeding should be considered gastric mucosal pathology caused by bleeding, along the side of the greater curvature of the stomach incision of the gastric wall. Suction out a large amount of blood and blood clots in the gastric cavity, carefully check the gastric mucosa for hemorrhagic foci, if no obvious lesions of the gastric mucosa such as hemangiomas are found, attention should be paid to checking the gastric mucosa in the cardia area. In general, the gastric mucosa of patients with peptic ulcer in special location is normal, there is no varicose vein on the surface of the mucosa, only active bleeding spots can be seen on the side of the small curvature of the gastric cardia area, and the gastric mucosa is found to have pinpoint dot-like superficial erosion or mucous membrane defect or rash-like elevation under careful observation, and there is sweating oozing or jetting bleeding on the surface, and the surrounding mucous membrane of the lesion is normal; if the bleeding stops, the mucous membrane surface may be adhered to the blood clots and the blood clots can be removed with absorbable gelatin sponges. If the bleeding stops, there may be blood clots attached to the mucosal surface, and the bleeding point can be found by removing the blood clots with an absorbent gelatin sponge; there are also lesions that show small arteries protruding from the center of the superficial gastric mucosal defect in the gastric lumen, and there is active bleeding; once a superficial confined lesion of the gastric mucosa is found with active bleeding on examination, it can be considered as a peptic ulcer in a special position, and the intraoperative examination can obtain a clear diagnosis as long as the special position of the special position of peptic ulcers and their pathologic features are fully understood. The diagnosis can be made by intraoperative exploration.
15 Differential diagnosisIn the diagnosis of peptic ulcer in special locations, attention should be paid to the MalloyWeiss tear and hemorrhagic gastric vasodilatation.
16 Treatment of specifically located peptic ulcersSpecifically located peptic ulcers have a high morbidity and mortality rate, with hemorrhagic shock and multiorgan failure being the leading causes of death. Early diagnosis and effective treatment are essential. Endoscopic treatment, selective left gastric artery embolization, and surgery are options.
16.1 Endoscopic treatmentMost patients with specifically located peptic ulcers can be successfully treated endoscopically. Endoscopic hemostasis success rates of 96% have been reported in the literature. Endoscopic treatments include injection therapy, thermal treatments such as heat probes, microwaves, high-frequency electrocoagulation, lasers, and instrumental treatments such as hemostatic clips and loopers.
16.1.1 (1) Injection therapyis the simplest treatment. As early as the 1970s there was a trial of endoscopic injection of 1% ethoxysclerol. Local injection of mucosal tissue edema, increase the pressure around the bleeding foci, compression of blood vessels, prompting the formation of intravascular thrombosis, injection of epinephrine can also make the local vasoconstriction, so as to achieve the effect of hemostasis. Injection method: routine endoscopy, found that the bleeding foci and fully exposed bleeding parts, through the endoscopic biopsy orifices sent into the endoscopic injection needle, at the same time will choose the drug first perfusion endoscopic injection needle tube, from the bleeding blood vessels 1 ~ 2 mm, divided into 3 ~ 5 points of the injection, the depth of 2 ~ 3 mm, effective for the fresh blood blackened, and then rinse the blood clots with iced water, supplemental injections, if necessary. Commonly used drugs are:
① anhydrous ethanol: 0.1 to 0.2 ml per point is appropriate, the total amount of 1 to 2 ml.
② sclerosing agent: 5% sodium cod liver oil acid acid or 1% ethyl oxysclerotinol, 0.2 to 0.5 ml per point of injection, the total amount of 2 to 4 ml.
③ high tensile sodium-adrenergic solution (HSE): 0.5 ml per point, the total amount of no more than 10 ml. Adverse effects of injection of sclerotherapy and anhydrous ethanol include ulcer formation, with attention to dose and depth.
16.1.2 (2) Thermal probe coagulation treatmentThermal probe coagulation hemostasis is a special thermal probe, inserted into the stomach through the endoscopic biopsy orifice, and contacted the bleeding foci under direct vision to stop the bleeding by coagulation of proteins, and the thermal probe is aligned with the bleeding foci under the direct vision of the endoscope and injected with water to rinse the blood clot on the surface of the lesion. Then the thermal probe was gently pressed on the bleeding foci and thermal coagulation was performed. After the color of the lesion becomes pale, water is injected to cool the probe and separate it from the coagulated tissue. If bleeding still occurs, the procedure can be repeated several times until the bleeding stops. After the bleeding stops, observe for a few minutes to make sure there is no more bleeding, then exit the endoscope. Thermal probe coagulation hemostasis method is simple, efficacy is true, safe, the instrument price is far cheaper than the laser.
16.1.3 (3) microwave coagulationendoscopic microwave coagulation therapy is to focus microwave energy in a small area, so that the tissue protein coagulation to achieve the purpose of hemostasis of a treatment method. Generally use the output wavelength 12cm, frequency 2450 MHz, power 100w microwave. Under direct endoscopic vision, the microwave probe is aligned and lightly pressed on the bleeding foci to perform microwave coagulation. The power is adjusted at 40～50w (50～60mA), and the coagulation time is 10～20s, so that the color of the diseased tissue becomes pale and the bleeding stops. After the application of microwave coagulation hemostasis, tissue repair is completed within 2 to 4 weeks. Endoscopic microwave coagulation hemostasis is easy to operate, and the equipment is inexpensive.
16.1.4 (4) High-frequency electrocoagulationThe use of high-frequency current in the local tissue to produce thermal effects, so that protein coagulation, vascular embolism to achieve the purpose of hemostasis. Electrocoagulation has little damage to the tissue, and can only be applied when there is a clear bleeding point, and a large amount of bleeding affects the hemostatic effect of electrocoagulation. Endoscopic examination found bleeding lesions, that is, connecting high-frequency power supply, and in the patient's calf discharge pole plate, test to determine the energization of normal. Coagulation current strength is usually selected 2 or 3, time 1 ~ 2 s. Select the appropriate probe, under direct endoscopic vision will be electrocoagulation head pressed on the bleeding site, connected to the coagulation current, can be repeated several times, until the tissue whitening bleeding stop. After stopping bleeding, observe for a few minutes, no further bleeding, you can exit the electrocoagulation head and endoscope. After electrocoagulation, the electrode adheres to the scorched tissue, and if the probe is pulled hard, it is easy to bring down the scorched tissue, causing rebleeding. Therefore, when removing the electrocoagulation head, it is necessary to stop energizing first to prevent secondary bleeding. High-frequency electrocoagulation hemostasis is simple to operate, and is suitable for various bleeding situations such as jet bleeding, active oozing, with hemispherical blood vessels showing and scattered bleeding spots.
16.1.5 (5) laser therapyThe use of laser irradiation tissue surface absorption can be converted into the principle of thermal energy, the irradiated local tissue absorption of light energy that is generated by high temperatures, so that the protein coagulation, vaporization of water, to achieve the purpose of photocoagulation hemostasis. After endoscopy to find the bleeding lesion, from the biopsy orifice into the quartz fiber electrode, aligned with the bleeding lesion, the distance of 0.5 ~ 1.0cm, each time 1 ~ 3s, repeat irradiation, until the bleeding lesion mucosa whitening or dark brown that bleeding stops. Endoscopic laser irradiation hemostasis is reliable, and can be used in any part of the gastrointestinal tract that can be reached by endoscopy. However, laser photocoagulation therapy equipment is expensive, and mobility is a disadvantage. In addition, laser hemostatic therapy can cause some serious complications, such as gastrointestinal perforation, bleeding and gastrointestinal distension. The main causes of gastrointestinal perforation are selecting too much power or too long a time for 1 irradiation. The incidence of perforation is 1%.
16.1.6 (6) Injections combined with thermal therapyInjections combined with one of the above thermal therapies can improve hemostasis, with temporary hemostasis after drug injection, improving the visibility of the bleeding point, and making thermal therapy hemostasis more precise and effective.
16.1.7 (7) Hemostatic Clamp TherapyThe principle of the hemostatic clamp is similar to that of the biopsy forceps, but the flap is in the shape of a clamp, and the clamp can be disintegrated from the operative part while still clamping the vessel after clamping a small vessel. A few days later, when it comes off, there is blood clot formation, so as to achieve the purpose of hemostasis. Hemostatic clips are mainly suitable for bleeding from vascular exposed lesions, 1 time unsuccessful, can be repeated several times until hemostasis is satisfactory.
16.1.8 (8) Sleeve treatmentSleeve treatment is relatively easy to operate compared with other endoscopic treatments, especially for lesions in the esophagogastric union and the posterior wall of the upper gastric body. Lesions with a diameter of 1 cm or less can be ligated, and the lesion can be sucked into the transparent cap at the top of the endoscope, with a clear field of vision and a definite hemostatic effect. However, the installation of the ligature takes time. It can be chosen for those who are ineffective after injection treatment or recurrent bleeding. The mucosal surface of the ligation site forms an ulcer after the operation and does not form recurrent bleeding.
16.2 EmbolizationSelective abdominal arteriography and embolization for the treatment of specifically located peptic ulcers have been reported less frequently. It should be a particularly useful treatment for those who have failed endoscopic therapy and cannot tolerate surgery. Four patients were reported in the literature to have undergone selective celiac arteriography with embolization of the left gastric artery; bleeding stopped after treatment in three cases, and surgical intervention was performed in the other case where treatment failed. Three conditions must be present for the choice of embolization:
(1) Superselective access of the cannula to the left gastric artery.
(2) Angiographic definition of the lesion and bleeding point without collateral vessels.
(3) Vital signs are stable and there is enough time for embolization to be performed gracefully.
16.3 SurgerySurgery used to be considered the treatment of choice for specifically located peptic ulcers. With advances in endoscopic treatment, surgical treatment has tended to be preceded by endoscopic treatment, and decisive surgery should be performed if endoscopic treatment is ineffective. Surgical methods include electrocoagulation at the bleeding point, suture hemostasis, proximal gastrectomy and local wedge resection. Electrocoagulation and suture method is simple, but postoperative bleeding is easy to recur, recently more advocate for extensive gastric wedge resection, because the constant diameter artery in the gastric mucosa travels longer, after resection can remove the cause of the disease, to avoid recurrence of bleeding, and can be resected specimens for pathological examination to obtain the final diagnosis. The gastric mucosa should be carefully examined during the operation to clarify the location of the peptic ulcer lesion in the special location, and when the bleeding point or lesion can not be clarified, it is contraindicated to carry out blind Billroth II type gastric resection of the large part of the stomach, if such an operation is carried out, the postoperative bleeding will definitely be repeated, and the prognosis is very poor.
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17 Related MedicinesAbsorbent gelatin sponge, oxygen, epinephrine, sodium cod liver oil acid
18 Related TestsHemoglobin
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