military aneurysm. in 1898 , dieulafoy , a french surgeon , referred to these lesions as exulceratio simplex and felt that these were the result of injury to the gastric mucosa with subsequent haemorrhage from a normal submucosal artery . dl is a persistent calibre artery anomaly that is relatively rare yet possibly fatal because of gastrointestinal bleeding . advances in endoscopic technique have greatly assisted in early diagnosis and added various options for the treatment for this lesion . a 51-year - old male patient had massive haematemesis and presented to us in hypovolemic shock . the patient had a body mass index ( bmi ) of 28 , had multiple comorbidities including uncontrolled diabetes , hypertension and hypercholesterolemia . he was not on any antiplatelet medication or nonsteroidal anti - inflammatory drugs ( nsaids ) . it showed a dilated tortuous vessel in the gastric fundus with active spurting from a superficial ulcer overlying it . however , within 48 h , the patient had a repeat bout of haematemesis for which repeat endoscopy and glue injection was done . computed tomography ( ct ) of the abdomen with ct angiography failed to reveal any obvious focus of bleeding . check endoscopy done after 72 h did not show any active oozing from the vessel . the patients had a further bout of massive haematemesis on the 5th day , wherein a surgical consultation was sought . a differential diagnosis of dl was strongly considered and urgent surgical intervention was done . at laparoscopy , wedge resection of the fundus was done using staplers and final histopathology diagnosis was consistent with a dl . the patient was fed 72 h after a gastrografin failed to demonstrate a leak and then discharged and is well at follow - up . paul georges dieulafoy ( 1839 - 1911 ) , a professor of pathology in paris , france was the first to describe a series of patients who presented with massive haematemesis due to a bleeding gastric vessel without any evidence of ulceration at autopsy . dl is histologically a normal vessel with an abnormally large diameter maintaining a consistent width of 1 - 3 mm . it runs a tortuous course within the submucosa and typically the lesion protrudes through a small mucosal defect varying from 2 - 5 mm with fibrinoid necrosis at its base . the fundus of the stomach within 6 cm of the cardia on the lesser curvature is the most common site for dl . this is attributed to the architecture of blood supply to the lesser curve of the stomach as vessels arise directly from the arterial chain . in the remainder of the stomach , they are twice as common in males as females , more commonly seen in the elderly population . associated comorbidities are present in more than 50% of patients , most frequently cardiac and renal diseases . failure to diagnose dl is often attributed to excessive blood or the fact that the lesion was subtle and hence , overlooked . endoscopic ultrasound can aid in the diagnosis and additionally bleed provocation test by intravenous ( iv ) heparin bolus . characteristic endoscopic findings include isolated protruding vessel surrounded by normal mucosa , which does not have an associated ulcer . in actively bleeding lesions , blood could be seen spurting or oozing from the pinpoint defect . in the absence of bleeding meticulous inspection of the gastric mucosa , especially in the well distended upper part of the stomach , is essential for an adequate diagnosis . endoscopic therapy is usually successful in achieving primary haemostasis ; with success rates reaching 75 - 100% . treatment options are dependent on the mode of presentation , site of the lesion and availability of expertise . endoscopic haemostatic procedures can be classified into three groups , thermal [ heater probe , argon plasma coagulation ( apc ) ] , regional ( adrenaline , sclerosants ) and mechanical ( bands or hemoclips ) . combination endoscopic therapy is known to be superior to monotherapy because of the lower rate of recurrent bleeding . mechanical therapies including hemoclips and band ligation are more effective and successful in controlling bleeding than other methods . advances in endoscopic therapy have reduced mortality in patients with dl from 80% to 8% . indications for selective angiography include failed endoscopic therapy , lesions beyond the reach of therapeutic endoscope and poor candidates for surgery . additionally , embolisation carries a risk of ischemia to the area supplied by the relevant artery . surgical treatment was historically the first line of treatment for dl of the stomach in the form of gastrectomy . surgical resection is currently reserved for 5% of cases that are refractory to endoscopic or angiographic measures . currently , minimal invasive surgery has been shown to play a greater role in the surgical management of a dl that fails endoscopic treatment . intraoperative or preoperative endoscopy has been used for localisation and laparoscopic resection of dl has been successfully performed . real - time operative endoscopy with picture - in - picture viewing is a powerful surgical tool allowing for simultaneous intra and extraluminal views . the endoscopic view allows for haemostasis to be ensured and for precise anatomical excisions to be performed , especially in cases requiring preservation of the pylorus . in this case , as the lesional haematoma and the subsequent attempts at endoscopic control left a serosal mark , endoscopic intraoperative localisation was unnecessary . plus , the endoscopic video provided a fairly accurate localisation of the bleeding site . in cases , as in this , when one suspects or sees proximity to the gastroesophageal ( ge ) junction , it is advisable to place a bougie or calibration tube in the oesophagus to prevent narrowing the gastric inlet , as we do in any stapling near the ge junction . in cases of prior glue injection , the surgeon has to be careful to avoid stapling on the glued site to prevent jamming the stapler or breaking the blade .
dieulafoy 's lesion ( dl ) is a relatively rare , but potentially life - threatening condition . 
 it accounts for 1 - 2% of acute gastrointestinal bleedings . 
 its serious nature makes it necessary for early diagnosis and treatment . 
 this is a case report of a patient who presented with life - threatening haematemesis due to gastric dieulafoy 's that was successfully treated laparoscopically after failed endotherapy .