Upper gastrointestinal bleeding is a common and serious medical problem with high morbidity and mortality rates. Every year approximately 100 patients per 100 000 inhabitants are admitted to hospital with this condition. The mortality rate is more than 8 % (1), depending on age, comorbidity and the cause of bleeding.
Massive bleeds require circulatory stabilising and frequently blood transfusions. Afterwards, gastroscopy should be performed as soon as possible in order to find the cause and location of the bleeding, and in order to provide initial treatment and evaluate the risk of rebleeding.
Gastroscopy normally makes it easy to establish the cause and location of the bleeding, and this allows haemostasis treatment to commence. Occasionally, blood or coagula will cover the lesion, thus making it difficult to locate and stop the bleed. If the bleeding is persistent, angiography may be used to establish its focus, in which case artery embolisation may stop the bleeding. The latter treatment option is available only at the largest hospitals in Norway.
The case history at hand was one of intermittent upper gastroenterological bleeding. Normal gastroscopy findings without the presence of blood or coagula represent major challenges, even for experienced endoscopists. Repeat gastroscopies, preferably while the patient is bleeding, will help locate the focus of the bleeding (2). In the case of Dieulafoy’s lesion, however, the bleeding stems from a dilated submucosal arteriole. The relevant artery may be obscured by a fold in the ventricle or duodenum and is frequently found by chance or thanks to persistent bleeding (3).
This particular patient had suffered major blood loss, but the first gastroscopy results were inconspicuous. There had been haematemesis, and the source of the bleed was therefore assumed to be located in the oesophagus, ventricle or duodenum. If an experienced gastroscopist is unable to find a potential source of bleeding in this type of patient, ulcus simplex is one of the first diagnoses that should spring to mind. Rarer conditions such as a primary or secondary aortoenteric fistula or a splenic artery aneurysm are also potential causes of bleeding (4). Where there is suspicion of upper gastrointestinal bleeding and the gastroscopy results are normal, it is important, irrespective of the patient’s gender and age, to keep in mind the possibility of Dieulafoy’s lesion.