DIEULAFOY 2 CASOS

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Endoscopia. 2015;27(1):42---44

www.elsevier.es/endoscopia

ENDOSCOPIA

CASO CLNICO

Lesin de Dieulafoy. Presentacin de 2 casos

Jose Daniel Martinez Quintanaa, y Karen Avila Tinajerob

a Unidadde Endoscopia Gastrointestinal, Hospital Regional de Coatzacoalcos Dr. Valentn Gmez Farias, Coatzacoalcos, Veracruz,

Mxicob Servicio de Ciruga General, HospitalGeneral de Veracruz, Veracruz, Veracruz, Mxico

Recibido el 25 de diciembre de 2014; aceptado el 20 de enero de 2015Disponible en Internet el 7 de abril de 2015

PALABRAS CLAVELesin de Dieulafoy;Hemorragia digestiva;Endoscopia

Resumen La lesin de Dieulafoy es una anomala vascular, rara pero potencialmente fatal dehemorragia gastrointestinal, y constituye menos del 2% de las causas de hemorragia digestivaaguda. El tratamiento endoscpico empleando diferentes mtodos es el de eleccin teniendoque recurrir en pocos casos a la ciruga. Se presentan 2 casos de lesin de Dieulafoy con manejoendoscpico exitoso 2014 Asociacin Mexicana de Endoscopia Gastrointestinal. Publicado por Masson DoymaMxico S.A. Todos los derechos reservados.

KEYWORDSDieulafoys lesion;Gastrointestinalbleeding;Endoscopy

Dieulafoys lesion. Presentation of2 cases

Abstract Dieulafoys lesion is a rare vascular anomaly with potentially fatal gastrointestinalbleeding that constitutes less than 2% of the causes of acute gastrointestinal bleeding. Endos-copic therapy using different methods is the treatment of choice, having to resort to surgeryin rare cases. Two cases of Dieulafoys lesion, with successful endoscopic management, arepresented. 2014 Asociacin Mexicana de Endoscopia Gastrointestinal. Published by Masson Doyma MxicoS.A. All rights reserved.

Autor para correspondencia. Fidel Velazquez # 2, Colonia H. J.Aldana Cosoleacaque, Veracruz C.P. 96340,Telfono:+529222283315.

Correo electrnico: danielmartinez [email protected](J.D. Martinez Quintana).

Introduccin

La lesin de Dieulafoy fue descrita con ms precisin hacia1897 por Dieulafoy1, denominndose inicialmente exulcera-tio simples creyendo que era el estadio inicial de una lceragstrica2. Se trata de una anomala vascular localizada gene-ralmente en estmago proximal, aunque se han descrito

http://dx.doi.org/10.1016/j.endomx.2015.01.0050188-9893/ 2014 Asociacin Mexicana de Endoscopia Gastrointestinal. Publicado por Masson Doyma Mxico S.A. Todos los derechosreservados.

men o escarga o e p: www.elsevier.es el . opia para uso personal, se pro e la ransmisi n e es e ocumen o por cualquier me io o orma o.
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Lesin de Dieulafoy. Presentacin de 2 casos 43

en esfago, duodeno, yeyuno, colon y recto1---3 as comoen bronquios4---6; es una causa rara aunque potencialmentefatal de hemorragia gastrointestinal7 y responde a menosdel 2% de los episodios de hemorragia digestiva aguda3,4. Esms frecuente en varones2 y se presenta a una edad mediade 60 anos, pero puede aparecer a cualquier edad, inclusoen ninos de muy corta edad3,6. El tratamiento endoscpicoempleando diferentes mtodos es el de eleccin6-8, teniendo

que recurrir en pocos casos a la ciruga3,9.

Casos clnicos

Presentacin de 2 casos clnicos

Caso 1

Paciente masculino de 17 anos de edad el cual se presenta alservicio de urgencias por presentar cuadro de hemorragia detubo digestivo alto de manera sbita y que lo llev a inestabi-lidad hemodinmica e ingreso en planta de medicina interna

con una anemia de 7 g/dl y un 21% de hematocrito. Se logrla estabilidad hemodinmica y fue sometido a endoscopiaalta en la cual se observa edema de la mucosa de estmagoy restos sanguneos sin lesiones en esfago ni estmago, peroevidenciando una lesin sobre la primera porcin del duo-deno con sangrado en capa sin proceso ulceroso (fig. 1).Se procede a realizar inyeccin de 10 ml de adrenalina1:10,000 en 4 cuadrantes, logrando controlar el sangrado yobservando los cambios postinyeccin (fig. 2). El pacientepresenta recurrencia del sangrado en la madrugada, lle-vndolo a choque hipovolmico con una hemoglobina de3 g/dl y necesitando apoyo con aminas e intubacin traquealcon vigilancia en la terapia intensiva; se le realiza nuevaendoscopia, observando nuevamente la lesin. Se le aplicainyeccin de 8 ml de adrenalina 1:10,000, observando cam-bios posteriores, y la evolucin del paciente es favorable conalta de terapia a los 3 das y posteriormente de hospital.

Figura 1 Sangrado pulstil de lesin de Dieulafoy en primeraporcin del duodeno.

Figura 2 Cambios posteriores a la aplicacin de adrenalina1:10,000.

Caso 2

Paciente femenina de 60 anos que se present con hemorra-gia digestiva alta manifestada por hematemesis y que leprodujo inestabilidad hemodinmica con un descenso dela hemoglobina de 6.5 g/dl. Tras control hemodinmico esenviada al rea de endoscopia para realizar estudio endos-cpico alto; en la endoscopia se observa esfago normal conpresencia en estmago de una lesin prepilrica sobre unrea de edema con sangrado en capa y sin proceso ulcerosoagregado, hay un cogulo pequeno formado que se movi-liza con agua; se decide inyeccin de adrenalina 1:10,000

de 10 ml en cuadrantes, logrando control del sangrado yobservando los cambios debidos a la inyeccin; se verificaausencia de sangrado y se enva de regreso a hospital dereferencia. Tras el seguimiento la paciente es dada de altaa los 3 das sin cuadro recurrente de sangrado (figs. 3 y 4).

Conclusiones

La lesin de Dieulafoy constituye menos del 2% de las cau-sas de hemorragia digestiva aguda1,3, y hasta el 80% de ellasse localizan en la zona proximal gstrica hacia la curvaturamenor que es donde estn las arterias de mayor calibre4,10;no obstante, se han comunicado casos en esfago, duodeno,

yeyuno, colon, recto y ano3,10---12. Los criterios endoscpi-cos para definir esta lesin son: a) la salida a chorro o flujomicropulstil de sangre arterial, activamente a partir de undefecto mucoso menor de 3 mm o travs de una mucosamacroscpicamente normal; b) la visualizacin de un vasocon o sin signos de sangrado reciente, que protruye a tra-vs de un defecto mucoso mnimo o a travs de la mucosanormal, y c) la presencia de cogulo fresco fuertementeadherido a travs de un punto estrecho de insercin sobreun defecto mnimo o mucosa aparentemente normal1,3,7.

Si la lesin es documentada por endoscopia, debe deintentarse la hemostasia a travs de mtodos endoscpi-cos como son: electrocoagulacin multipolar, heater probe,



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44 J.D. Martinez Quintana, K. Avila Tinajero

Figura 3 Lesin con sangrado en capa en antro gstrico.

Figura 4 Lesin del antro gstrico con sangrado en capa.

hemo-clips, argn plasma, inyeccin de adrenalina, poli-docanol o etanolamina; otras tcnicas como la angiografacon embolizacin y la ciruga deben de contemplarse enpaciente en quienes no es posible el control hemodinmicoo presentan recurrencias en ms de 2 ocasiones tras tcni-cas endoscpicas. En el estudio de Lopez-Arce la terapiaendoscpica combinada de gold probe y epinefrina mos-tr excelentes resultados sin que los pacientes requirieranciruga12. Pueden realizarse otras tcnicas, pero en un cen-tro en donde la tcnica endoscpica sea limitada estacombinacin da buenos resultados.

Responsabilidades ticas

Proteccin de personas y animales. Los autores declaranque para esta investigacin no se han realizado experimen-tos en seres humanos ni en animales.

Confidencialidad de los datos. Los autores declaran que eneste artculo no aparecen datos de pacientes.

Derecho a la privacidad y consentimiento informado. Losautores declaran que en este artculo no aparecen datos depacientes.

Financiacin

Los autores no recibieron patrocinio para la realizacin delartculo.

Conflicto de intereses

No se reportan conflictos de intereses.

Bibliografa

1. Botello Z. Tratamiento endoscpico de lesiones de Dieulafoy.Rev Esp Md Quir. 2013;18:322---7.

2. Amrut P, Sampat S, Motilal P, et al. Dieulafoy disease of stomach- An uncommon cause of gastrointestinal system bleeding. JAssoc Phys India. 2014;62:66---8.

3. Rivera R, Mndez I, Ubiana E, et al. Hemorragia digestivaseverapor lesinde Dieulafoyduodenal. Rev GatroenterolPer.2006;26:203---6.

4. Baxter M, Aly EH. Dieulafoys lesion: Current trends in diagnosisand management. Ann R Coll Surg Engl. 2010;92:548---54.

5. Parrot A, Antoine F, Khalil A, et al. Approach to diagnosis and

pathological examination in bronchial Dieulafoy disease: A caseseries. Respir Res. 2008;9:58.

6. Zavras N, Siafakas C, Pergamalis G, et al. Successful diagnosisand treatment of Dieulafoys lesion with endoscopy and ther-mocoagulation in a full-term neonate: Report of a case andliterature review. JPS Case Reports. 2014;2:250---3.

7. Marcelo ML, Benedito HF, Vladimir S. Dieulafoy lesion: Endos-copic and surgical management. Surg Laparosc Endosc PercutanTech. 2006;16:1---3.

8. Close LN, Kumar NC, Glazer ES, et al. A Dieulafoy lesion as thecause of massive upper gastrointestinal bleeding after a distalpancreatectomy and splenectomy: Case report and literaturereview. J Surg. 2013;1:1---3.

9. Soney Y, Kumada T, Toyoda H, et al. Endoscopic managementand follow up of Dieulafoy lesion in the upper gastrointestinal

tract. Endoscopy. 2005;37:449---53.10. Schmulewitz N, Baillie J. Dieulafoy lesions: A review of 6 years

of experience at a tertiary referral center. Am J Gastroenterol.2001;96:1688---94.

11. Martnez AD, Souto RJ, Ynez LJ, et al. Enfermedad deDieulafoy recidivante tratada quirrgicamente: diagnsticomediante ultrasonografa endoscpica. Rev esp enferm dig.2004;96:138---42.

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DIEULAFOY 2 CASOS

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