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Severe Erosive Hemorrhagic Gastritis in a Pediatric Patient

Friedlander, Joel*; Shehab, Samir; Harrison, Marvin; Zhang, Zili§

Journal of Pediatric Gastroenterology & Nutrition: August 2012 - Volume 55 - Issue 2 - p 119
doi: 10.1097/MPG.0b013e318246deca
Image of the Month

*Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Children's Hospital of Colorado, University of Colorado Health Sciences Center, Aurora, CO

Northwest Permanente

Department of Surgery, Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health and Science University

§Department of Pediatrics, Division of Pediatric Gastroenterology, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR.

Address correspondence and reprint requests to Joel Friedlander, DO, M.Be, Digestive Health Institute, Anschutz Medical Campus, 13123 East 16th Avenue, B290, Aurora, CO 80045 (e-mail:

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

The authors report no conflicts of interest.

An 11-year-old-Hispanic boy with relapsed acute lymphocytic leukemia presented with hematemesis and melena 1 week after admission for sepsis and rhabdomyolysis. He had presyncope and presented to an outside hospital with hemoglobin 8.4 mg/dL. His recent chemotherapeutic experimental protocol included epratuzumab, vincristine, PEG-asparaginase, prednisone, and intrathecal methotrexate. He denied NSAID use and was on ranitidine prophylaxis. His physical examination was remarkable for a pale, cushingnoid male with hepatomegaly (14 cm) and without splenomegaly. Rectal examination demonstrated melanotic stool. The balance of the examination was unremarkable.

The patient underwent esophagogastroduodenoscopy once he was hemodynamically stable. The gastric mucosa was diffusely ulcerated, with numerous visible vessels. (Fig. 1) Argon plasma coagulation to treat diffuse disease was not available. Bipolar cautery was applied. Initial biopsies showed focal active inflammation and regenerative changes (Fig. 2). Gastrin level was normal and cytomegalovirus, Epstein-Barr virus, herpes simplex virus, adenovirus, Helicobacter pylori testing was negative. Despite a pantoprazole drip, bleeding recurred in a now deep ulcer within the gastric fundus (Fig. 3), which required epinephrine injection, bipolar cautery, and endoscopic clipping. Bleeding subsequently recurred at requiring massive transfusion protocol. Interventional radiology was unsuccessful, achieving hemostasis, and a partial gastric resection with use of factor VIIa was performed. Pathology showed severe ulceration, necrosis, hemorrhage, inflammation, and thrombosis (Fig. 4). No leukemic infiltrate was found. Subsequently, the patient did well.

Severe gastrointestinal bleeding from severe hemorrhagic and erosive gastritis in pediatrics is rarely reported. The cause here is likely multifactorial (1). There are limited pediatric reports on the causes of such severe erosive and hemorrhagic gastritis. This patient did not have an oncologic infiltrate, viral infection, Zollinger-Ellison syndrome, or report NSAID use (2–5). We suspect that the cause was chemotherapeutics and recent sepsis with Cushing ulcer.

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© 2012 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,