Massive Gastrointestinal Bleeding from a Dieulafoy Lesion in a Seven Year Old Boy Amana N. Nasir, Carolyn M. Wilhelm, Joel A. Levien, John N. Udall, Jr.

Massive Gastrointestinal Bleeding Massive Gastrointestinal Bleeding from a Dieulafoy Lesion in a Seven from a Dieulafoy Lesion in a Seven

Year Old Boy Year Old Boy

Amana N. Nasir, Carolyn M. Wilhelm, Amana N. Nasir, Carolyn M. Wilhelm, Joel A. Levien, Joel A. Levien,

John N. Udall, Jr.John N. Udall, Jr.

History of Present IllnessHistory of Present Illness

A 7yo boy was transferred to WCH from an A 7yo boy was transferred to WCH from an outside hospital with a right lung pneumonia outside hospital with a right lung pneumonia and pleural effusion.and pleural effusion.

He had received amoxicillin, azithromycin He had received amoxicillin, azithromycin and 5 days of high dose ibuprofen prior to and 5 days of high dose ibuprofen prior to being hospitalized at the outside facility. being hospitalized at the outside facility.

Past Medical HistoryPast Medical History

Unremarkable for chronic illnessesUnremarkable for chronic illnesses

No chronic medications No chronic medications

There had been no hospitalizations or There had been no hospitalizations or surgeriessurgeries

No known drug allergiesNo known drug allergies

Admission Chest RadiographsAdmission Chest Radiographs

Hospital Day 1Hospital Day 1

Hemoglobin 11.3gm%Hemoglobin 11.3gm%

Hematocrit 32.3 %Hematocrit 32.3 %

Started on IV ceftriaxone and vancomycinStarted on IV ceftriaxone and vancomycin

Hospital Day 2Hospital Day 2

Right chest tube placedRight chest tube placed

He vomited 15cc of blood and passed He vomited 15cc of blood and passed melanotic stools during the nightmelanotic stools during the night

Transferred to the PICU Transferred to the PICU

His H/H fell to 7.4 gm% / 21.7% (admission His H/H fell to 7.4 gm% / 21.7% (admission H/H were 11.3 gm% / 32.3%)H/H were 11.3 gm% / 32.3%)

Two units PRBCs and 1 unit FFP were givenTwo units PRBCs and 1 unit FFP were given

Started on IV pantoprazoleStarted on IV pantoprazole

Hospital Day 3Hospital Day 3

Pediatric GI service consultedPediatric GI service consulted

Pediatric GI examination Pediatric GI examination – Tachypneia, tachycardia and normal BPTachypneia, tachycardia and normal BP– Tenderness in the epigastriumTenderness in the epigastrium– Rectal examination was followed by the Rectal examination was followed by the

passage of grossly bloody stoolpassage of grossly bloody stool

Impression- gastritis and/or stress ulcer Impression- gastritis and/or stress ulcer

Plan- close observation, consider EGDPlan- close observation, consider EGD

Hospital Day 4Hospital Day 4

H/H increased to 10.3 gm% / 29.5%H/H increased to 10.3 gm% / 29.5%

Sucralfate slurries were added Sucralfate slurries were added

Decrease in melanotic stoolsDecrease in melanotic stools

No additional hematemasisNo additional hematemasis

Continued epigastric discomfortContinued epigastric discomfort

Hospital Day 9Hospital Day 9

The pt. had a 2The pt. had a 2ndnd episode of hematemesis episode of hematemesis

(40-50ccs)(40-50ccs)

H/H dropped to 8.5gm% / 25.3 %H/H dropped to 8.5gm% / 25.3 %

EGD performed (1EGD performed (1stst EGD) EGD)– Blood clots throughout the stomach but no active Blood clots throughout the stomach but no active

bleedingbleeding– 2 moderate sized duodenal ulcers2 moderate sized duodenal ulcers

(one with a white eschar base and one with an overlying clot)(one with a white eschar base and one with an overlying clot)

Started on IV pantoprzole and octreotide drips Started on IV pantoprzole and octreotide drips

Transfused 3 units PRBCs & 1 unit of FFP Transfused 3 units PRBCs & 1 unit of FFP

Cardia of stomach and pylorusCardia of stomach and pylorus(1(1stst EGD) EGD)

Ulcer eschar and ulcer with clotUlcer eschar and ulcer with clot

Hospital Day 10Hospital Day 10

The patient became pale, diaphoretic and The patient became pale, diaphoretic and hypotensive hypotensive

NG tube placed and blood suctionedNG tube placed and blood suctioned

The patient was taken for emergency The patient was taken for emergency EGD (2EGD (2ndnd EGD) EGD)

Hospital Day 10Hospital Day 10At EGD the same clean based ulcer with At EGD the same clean based ulcer with an eschar was seen in the duodenal bulb an eschar was seen in the duodenal bulb and in the duodenal sweep a blood clot and in the duodenal sweep a blood clot overlying a moderate sized blood vessel overlying a moderate sized blood vessel was noted was noted

The area around the blood vessel was The area around the blood vessel was injected with 2.5mL of 1:10,000 injected with 2.5mL of 1:10,000 epinephrineepinephrine

The area and ulcer base was then gently The area and ulcer base was then gently cauterized with a Gold heater probe cauterized with a Gold heater probe

Cautery with Gold heater probeCautery with Gold heater probe(2(2ndnd EGD) EGD)

Hospital Day 11-16Hospital Day 11-16

Following the 2Following the 2ndnd EGD the patient was EGD the patient was transfused with 4 more units of PRBCs. He transfused with 4 more units of PRBCs. He remained stable with no signs of bleeding.remained stable with no signs of bleeding.On the 16On the 16thth day the patient had a third episode of day the patient had a third episode of hematemesis (400cc) that required 2 units of hematemesis (400cc) that required 2 units of PRBCs.PRBCs.A fasting serum gastrin level was normal.A fasting serum gastrin level was normal.Possible surgical intervention was discussed Possible surgical intervention was discussed with the family. However, there was no with the family. However, there was no additional evidence of active bleeding.additional evidence of active bleeding.

Hospital Day 21Hospital Day 21

Prior to discharge another endoscopy (3Prior to discharge another endoscopy (3rdrd EGD) was performed. There was no active EGD) was performed. There was no active bleeding, no blood clots and both duodenal bleeding, no blood clots and both duodenal ulcers appeared to be healing.ulcers appeared to be healing.

Biopsies from the gastric antrum showed Biopsies from the gastric antrum showed chronic gastritis but no Helicobacter pylori.chronic gastritis but no Helicobacter pylori.

The patient was discharged on high doses of The patient was discharged on high doses of pantoprazole, ranitidine and sucralfate.pantoprazole, ranitidine and sucralfate.

Pylorus and healing Diuelofy lesionPylorus and healing Diuelofy lesion(3(3rdrd EGD) EGD)

SummarySummary

During his WCH stay our patient received a During his WCH stay our patient received a total of 11 units of PRBCs and 2 units of total of 11 units of PRBCs and 2 units of FFPFFP

On discharge his H/H was 12.6gm%/ 36.8%On discharge his H/H was 12.6gm%/ 36.8%

Follow upFollow up

At a clinic visit two weeks after discharge he was stable. At a clinic visit two weeks after discharge he was stable. There had been no further hematemesis or melena . There had been no further hematemesis or melena . The H/H was 14.2 gm% / 42%. He was taking The H/H was 14.2 gm% / 42%. He was taking pantoprazole 20 mg tid, ranitidine 75 mg bid and pantoprazole 20 mg tid, ranitidine 75 mg bid and sucralfate 500 mg qid. The same medications and sucralfate 500 mg qid. The same medications and doses were continued except for the sucralfate which doses were continued except for the sucralfate which was discontinued. was discontinued.

At a clinic visit six weeks after discharge he remained At a clinic visit six weeks after discharge he remained asymptomatic. The H/H was 13.2 gm% / 38.5%. The asymptomatic. The H/H was 13.2 gm% / 38.5%. The ranitidine was discontinued at the six week visit and the ranitidine was discontinued at the six week visit and the pantopazole was decreased to 20 mg bid.pantopazole was decreased to 20 mg bid.

Dieulafoy lesionDieulafoy lesion

First described by T. Gallard in 1884 and later First described by T. Gallard in 1884 and later by G. Dieulafoy in 1896by G. Dieulafoy in 1896Proposed etiology- an unusually large and Proposed etiology- an unusually large and tortuous artery that runs in the submucosa tortuous artery that runs in the submucosa – massive bleeding occurs when the vessel is massive bleeding occurs when the vessel is

exposed or erodes as it approximates the exposed or erodes as it approximates the mucosamucosa

Most common in the lesser curvature of the Most common in the lesser curvature of the stomach, but reported to occur in bronchi and stomach, but reported to occur in bronchi and in the esophagus, small and large intestine in the esophagus, small and large intestine

Accounts for less than 2% of all upper GI Accounts for less than 2% of all upper GI bleedsbleeds– May be underestimated due to difficulty in May be underestimated due to difficulty in

diagnosisdiagnosis

Diagnosis may be complicated due to the Diagnosis may be complicated due to the intermittent nature of the bleeding intermittent nature of the bleeding Found primarily in adults Found primarily in adults Twice as common in men as womenTwice as common in men as women

Rarely reported in the pediatric populationRarely reported in the pediatric population– In the English literature, there have been 8 In the English literature, there have been 8

reported pediatric cases, ranging in age from reported pediatric cases, ranging in age from 13 months to 15 years 13 months to 15 years

To our knowledge, this is the third To our knowledge, this is the third pediatric case in the English literature of a pediatric case in the English literature of a small intestinal Dieulafoy lesion.small intestinal Dieulafoy lesion.

DiagnosisDiagnosis

The diagnosis is established by endoscopy but the The diagnosis is established by endoscopy but the lesion can be difficult to identifylesion can be difficult to identify

The lesion may be noted as a bleeding arteriole or The lesion may be noted as a bleeding arteriole or noted as a clot overlying a vessel (our case)noted as a clot overlying a vessel (our case)

In most cases the surrounding mucosa is normalIn most cases the surrounding mucosa is normal

Multiple endoscopic procedures may be necessary Multiple endoscopic procedures may be necessary before the lesion is foundbefore the lesion is found

The diagnosis in a few cases has been established The diagnosis in a few cases has been established by capsule endoscopy, arteriography or endoscopic by capsule endoscopy, arteriography or endoscopic ultrasoundultrasound

TreatmentTreatment

Endoscopic interventions (most commonly Endoscopic interventions (most commonly employed) employed) – injection of epinephrine or sclerosing agents, injection of epinephrine or sclerosing agents,

thermocoagulation, photocoagulation or band ligationthermocoagulation, photocoagulation or band ligation– In our case epinephrine injection and electrocaudery In our case epinephrine injection and electrocaudery

were usedwere used

Surgical interventions (less commonly Surgical interventions (less commonly employed)employed)– Reserved when endoscopic intervention failsReserved when endoscopic intervention fails– Includes over-sewing of the lesion or wide resection. Includes over-sewing of the lesion or wide resection. – Associated with more postoperative complicationsAssociated with more postoperative complications

Angiography with embolization has also been Angiography with embolization has also been used when the lesion is found in the jejunumused when the lesion is found in the jejunum

ConclusionConclusion

Dieulafoy lesions are rare in the pediatric Dieulafoy lesions are rare in the pediatric age group and can be difficult to diagnose. age group and can be difficult to diagnose.

Our case illustrates the success of Our case illustrates the success of endoscopy for diagnosis and treatment.endoscopy for diagnosis and treatment.

ReferencesReferences

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