Case

1. Massive Gastrointestinal Bleeding from a Dieulafoy Lesion in a Seven Year Old Boy Amana Nasir M.D., ,April Lawson N.P., Carolyn Wilhelm, Joel Levien M.D., John Udall M.D. WVU-PC Women and Children’s Hospital. Charleston, WV Dieulafoy’s lesion cont’d Treatment Case EGD # 1 Final Hemostasis • Prior to discharge another endoscopy (4thEGD) 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. • Fasting Gastrin levels-Normal • The patient was discharged on high doses of pantoprazole, ranitidine and sucralfate. • Pylorus and healing Diuelofy lesion • 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% • 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. • 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 • 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. • owley DM, Chasumba G, Zuckerman M. Life-threatening haemorrhage from a gastric Dieulafoy lesion in a child with haemophilia.Haemophilia. 2002 Sep;8(5):719-20. • 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. • 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. • Hemoglobin 11.3gm%,Hematocrit 32.3 % • Started on IV ceftriaxone and vancomycin • Right chest tube placed • He vomited 15cc of blood and passed melanotic stools during the night • 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 • Pediatric GI service consulted • Pediatric GI examination • Tachypnea, 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. • 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. • 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 Cardia of stomach and pylorus Medical management continued. 2 days later patient has massive hematemesis. Pre Discharge EGD EGD # 2 Ulcer with eschar and another with a clot and a cherry red spot- Epinephrine injected Hospital course Conclusion Diagnosis Hospital summary References EGD#3 Following day: patient had another episode of UGIB 2 gram drop in Hb. EGD and cautery with Gold heater probe Dieulafoy’s lesion Your references here