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.

History of Present Illness

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

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

Past Medical History

Unremarkable for chronic illnesses No chronic medications There had been no hospitalizations or surgeries No known drug allergies

Admission Chest Radiographs

Hospital Day 1

Hemoglobin 11.3gm% Hematocrit 32.3 % Started on IV ceftriaxone and vancomycin

Hospital Day 2

Right chest tube placed He vomited 15cc of blood and passed melanotic stools during the night Transferred to the PICU His H/H fell to 7.4 gm% / 21.7% (admission H/H were 11.3 gm% / 32.3%) Two units PRBCs and 1 unit FFP were given Started on IV pantoprazole

Hospital Day 3

Pediatric GI service consulted Pediatric GI examination – Tachypneia, tachycardia and normal BP – Tenderness in the epigastrium – Rectal examination was followed by the passage of grossly bloody stool Impression- gastritis and/or stress ulcer Plan- close observation, consider EGD

Hospital Day 4

H/H increased to 10.3 gm% / 29.5% Sucralfate slurries were added Decrease in melanotic stools No additional hematemasis Continued epigastric discomfort

Hospital Day 9

The pt. had a 2 nd episode of hematemesis (40-50ccs) H/H dropped to 8.5gm% / 25.3 % EGD performed (1 st EGD) – Blood clots throughout the stomach but no active bleeding – 2 moderate sized duodenal ulcers (one with a white eschar base and one with an overlying clot) Started on IV pantoprzole and octreotide drips Transfused 3 units PRBCs & 1 unit of FFP

Cardia of stomach and pylorus (1

st

EGD)

Ulcer eschar and ulcer with clot

Hospital Day 10

The patient became pale, diaphoretic and hypotensive NG tube placed and blood suctioned The patient was taken for emergency EGD (2 nd EGD)

Hospital Day 10

At EGD the same clean based ulcer with an eschar was seen in the duodenal bulb and in the duodenal sweep a blood clot overlying a moderate sized blood vessel was noted The area around the blood vessel was injected with 2.5mL of 1:10,000 epinephrine The area and ulcer base was then gently cauterized with a Gold heater probe

Cautery with Gold heater probe (2

nd

EGD)

Hospital Day 11-16

Following the 2 nd EGD the patient was transfused with 4 more units of PRBCs. He remained stable with no signs of bleeding.

On the 16 th day the patient had a third episode of hematemesis (400cc) that required 2 units of PRBCs.

A fasting serum gastrin level was normal.

Possible surgical intervention was discussed with the family. However, there was no additional evidence of active bleeding.

Hospital Day 21

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

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

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

Pylorus and healing Diuelofy lesion (3

rd

EGD)

Summary

During his WCH stay our patient received a total of 11 units of PRBCs and 2 units of FFP On discharge his H/H was 12.6gm%/ 36.8%

Follow up

At a clinic visit two weeks after discharge he was stable. There had been no further hematemesis or melena . The H/H was 14.2 gm% / 42%. He was taking pantoprazole 20 mg tid, ranitidine 75 mg bid and sucralfate 500 mg qid. The same medications and doses were continued except for the sucralfate which was discontinued. At a clinic visit six weeks after discharge he remained asymptomatic. The H/H was 13.2 gm% / 38.5%. The ranitidine was discontinued at the six week visit and the pantopazole was decreased to 20 mg bid.

Dieulafoy lesion

First described by T. Gallard in 1884 and later by G. Dieulafoy in 1896 Proposed etiology- an unusually large and tortuous artery that runs in the submucosa – massive bleeding occurs when the vessel is exposed or erodes as it approximates the mucosa Most common in the lesser curvature of the stomach, but reported to occur in bronchi and in the esophagus, small and large intestine

Accounts for less than 2% of all upper GI bleeds – May be underestimated due to difficulty in diagnosis Diagnosis may be complicated due to the intermittent nature of the bleeding Found primarily in adults Twice as common in men as women

Rarely reported in the pediatric population – In the English literature, there have been 8 reported pediatric cases, ranging in age from 13 months to 15 years To our knowledge, this is the third pediatric case in the English literature of a small intestinal Dieulafoy lesion.

Diagnosis

The diagnosis is established by endoscopy but the lesion can be difficult to identify The lesion may be noted as a bleeding arteriole or noted as a clot overlying a vessel (our case) In most cases the surrounding mucosa is normal Multiple endoscopic procedures may be necessary before the lesion is found The diagnosis in a few cases has been established by capsule endoscopy, arteriography or endoscopic ultrasound

Treatment

Endoscopic interventions (most commonly employed) – injection of epinephrine or sclerosing agents, thermocoagulation, photocoagulation or band ligation – In our case epinephrine injection and electrocaudery were used Surgical interventions (less commonly employed) – Reserved when endoscopic intervention fails – Includes over-sewing of the lesion or wide resection. – Associated with more postoperative complications Angiography with embolization has also been used when the lesion is found in the jejunum

Conclusion

Dieulafoy lesions are rare in the pediatric age group and can be difficult to diagnose. Our case illustrates the success of endoscopy for diagnosis and treatment.

References 1. Pitcher GJ, Bowley DM, Chasumba G, Zuckerman M.

Haemophilia.

2002 Sep;8(5):719-20.

Life-threatening haemorrhage from a gastric Dieulafoy lesion in a child with haemophilia.

2. Lilje C, Greiner P, Riede UN, Sontheimer J, Brandis M. Dieulafoy lesion in a one year-old child.

J Pediatr Surg

. 2004 Jan;39(1):133-4.

3. Sweerts M, Nicholson AG, Goldstraw P, Corrin B. Dieulafoy's disease of the bronchus.

Thorax.

1995 Jun;50(6):697-8.

4. Anireddy D, Timberlake G, Seibert D. Dieulafoy's lesion of the esophagus.

Gastrointest Endosc

. 1993 Jul-Aug;39(4):604.

5. Sai Prasad TR, Lim KH, Lim KH, Yap TL. Bleeding jejunal Dieulafoy pseudopolyp: capsule endoscopic detection and laparoscopic-assisted resection.

J Laparoendosc Adv Surg Tech A

. 2007 Aug;17(4):509-12.

6. Murray KF, Jennings RW, Fox VL. Endoscopic band ligation of a Dieulafoy lesion in the small intestine of a child.

Gastrointest Endosc.

1996 Sep;44(3):336-9.

7. Meister TE, Varilek GW, Marsano LS, Gates LK, Al-Tawil Y, de Villiers WJ. Endoscopic management of rectal Dieulafoy-like lesions: a case series and review of literature.

Gastrointest Endosc

. 1998 Sep;48(3):302-5. 8. Linhares MM, Filho BH, Schraibman V, Goitia Durán MB, Grande JC, Sato NY, Lourenço LG, Lopes-Filho GD. Dieulafoy lesion: endoscopic and surgical management.

Surg Laparosc Endosc Percutan Tech

. 2006 Feb;16(1):1-3.

9. Driver CP, Bruce J. An unusual cause of massive gastric bleeding in a child.

J Pediatr Surg

. 1997 Dec;32(12):1749-50.

10. Avlan D, Nayci A, Altintaş E, Cingi E, Sezgin O, Aksöyek S. An unusual cause for massive upper gastrointestinal bleeding in children: Dieulafoy's lesion.

Pediatr Surg Int.

2005 May;21(5):417-8. Epub 2005 Apr 2.