Transcript BKDieulafoy Lesion in a 7yo boy

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 2nd episode of hematemesis
(40-50ccs)
H/H dropped to 8.5gm% / 25.3 %
EGD performed (1st 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
st
(1 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 (2nd 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
(2nd EGD)
Hospital Day 11-16
Following the 2nd EGD the patient was
transfused with 4 more units of PRBCs. He
remained stable with no signs of bleeding.
On the 16th 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 (3rd
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
(3rd 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.
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