Dieulafoy's Vascular Malformation: Role of Endoscopic Ultrasonography in Therapeutic Decision-Making

Background: Dieulafoy's vascular malformation may cause severe, potentially life-threatening gastro-intestinal bleeding. Endoscopic diagnosis may be difficult because of minute mucosal lesions, and additional intramural abnormalities are usually not encountered. Endoluminal high-frequency ultrasonography is a new modality for imaging intramural and perivisceral structures. Methods: We report two cases of recurrent severe gastric bleeding in which different endosonographic modalities were used in the diagnosis of Dieulafoy's malformation, and the impact of endosonography on therapeutic strategy is discussed. In the first case a radial-scanning 7.5/12-MHz echoendoscope and a linear 20-MHz miniature probe were applied for B-mode imaging in a stable-state patient who had undergone previous endoscopic sclerotherapy, and arterial flow signals from the small intramural lesion were recorded using a 10-MHz transendoscopic pulsed Doppler probe. In the other case urgent endosonography was performed shortly after a bleeding episode, disclosing an aberrant large-calibre artery entering the gastric wall with a long submucosal branch. Results: Both patients were successfully operated on with a transabdominal approach. Conclusion: Endosonography is a quick and safe diagnostic method and should be considered when vascular malformations are suspected as the cause of gastric bleeding.