Massive Gastrointestinal Bleeding from a Dieulafoy Lesion in a Seven Year Old Boy

1
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.

2
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.

3
Past Medical History

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

4
Admission Chest Radiographs
5
Hospital Day 1

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

6
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

7
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

8
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

9
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

10
Cardia of stomach and pylorus(1st EGD)
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Ulcer eschar and ulcer with clot
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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)

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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 110,000 epinephrine
• The area and ulcer base was then gently
  cauterized with a Gold heater probe

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Cautery with Gold heater probe(2nd EGD)
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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.

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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.

17
Pylorus and healing Diuelofy lesion(3rd EGD)
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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

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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.

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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

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• 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

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• 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.

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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

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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

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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.

26
References

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