Professor Georges Dieulafoy had described Dieulafoy arteriole a century and half ago, yet, the pathogenesis and the mechanism of bleeding from this vascular anomaly had not been precisely appreciated [7]. Minor trauma to a point in the mucosa which is pressurized by the enlarged dilated arteriole has been postulated as the likely mechanism for a bleeding Dieulafoy arteriole [13].
Implication of endoscopy in the diagnosis and management of the bleeding Dieulafoy has reduced the need for surgical intervention, also, reduced high mortality perpetually ascribed for this condition [14].
The reported endoscopic definitions of Dieulafoy lesions are ranging from an arterial spurting, small pulsatile streaming from a minute (<3 mm) mucosal defects, a protruding vessel with or without active bleeding within a minute mucosal defect with normal surrounding mucosa to an adherent clot attached to a minute mucosal defect or a normally appearing mucosa [15].
Endoscopic techniques to obtain hemostasis in Dieulafoy bleeds have been progressing over time. From old to recent, pure injection therapy of adrenaline (1:10,000) or cyanoacrylate glue to combined injection therapy and either hemoclips, argon plasma electro-cautery or band ligation are all used as alternative endoscopic procedures in management of Dieulafoy bleeds [16, 17]. The reported success rate of these different endoscopic techniques is varying between 75 to 98% [1].
Pure injection endoscopic management, leukocytosis, reduced prothrombin concentration and the use of anti-platelet drugs have been mentioned in many studies as predictors for rebleeding of Dieulafoy lesion after first endoscopic hemostasis [18, 19].
The case in this report has received only cyanoacrylate injection as the primary endoscopic management, additionally he was under aspirin treatment for his cardiac insufficiency. Hence, he was prone for rebleeding after apparently primary endoscopic hemostasis.
Up till now, a consensus treatment for Dieulafoy bleeding is not available and different modalities are used depending on the patient's presentation and the endoscopic experience of the endoscopy personnel [20].
Ovesco clip (Tübingen, Germany), an over-the-scope clip is nitinol, biocompatible and mounted on an applicator cap. The Ovesco clip is endoscopically deployed into the bleeding Dieulafoy in a resembling manner to variceal band ligation [21]. The key to successful deployment is staying calm, lining up the lesion, suction and then deployment.
The few publications concerning the use of the over scope clipping technique in management of Dieulafoy bleeds have shown remarkable hemostatic achievements [21,22,23]. Hence, Ovesco clipping was chosen in purpose to obtain adequate hemostasis in this case after failure of the first cyanoacrylate and re-bleeding. Proper healing of the Dieulafoy lesion which was documented in the follow-up endoscopic examination has confirmed the effectiveness, of the Ovesco clipping technique in the management of such a critical case.
