Home Current Issue Previous Issues Published Ahead-of-Print CME Collections Podcasts For Authors Journal Info
Skip Navigation LinksHome > August 2012 - Volume 55 - Issue 2 > Severe Erosive Hemorrhagic Gastritis in a Pediatric Patient
Text sizing:
A
A
A
Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e318246deca
Image of the Month

Severe Erosive Hemorrhagic Gastritis in a Pediatric Patient

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

Free Access
Article Outline
Collapse Box

Author Information

*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: Joel.Friedlander@childrenscolorado.org).

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 http://www.jpgn.org, 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.

Figure 1
Figure 1
Image Tools
Figure 2
Figure 2
Image Tools
Figure 3
Figure 3
Image Tools
Figure 4
Figure 4
Image Tools

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.

Back to Top | Article Outline

REFERENCES

1. Soylu AR, Buyukasik Y, Cetiner D, et al. Overt gastrointestinal bleeding in haematologic neoplasms. Dig Liver Dis 2005; 37:917–922.

2. Chen ZM, Shah R, Zuckerman GR, et al. Epstein-Barr virus gastritis: an underrecognized form of severe gastritis simulating gastric lymphoma. Am J Surg Pathol 2007; 31:1446–1451.

3. Hokama A, Taira K, Yamamoto Y, et al. Cytomegalovirus gastritis. World J Gastrointest Endosc 2010; 2:379–380.

4. Kalach N, Bontems P, Koletzko S, et al. Frequency and risk factors of gastric and duodenal ulcers or erosions in children: a prospective 1-month European multicenter study. Eur J Gastroenterol Hepatol 2010; 22:1174–1181.

5. Nithiwathanapong C, Reungrongrat S, Ukarapol N. Prevalence and risk factors of stress-induced gastrointestinal bleeding in critically ill children. World J Gastroenterol: WJG 2005; 11:6839–6842.

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

Login

Article Tools

Images

Share

Connect With Us

 

 

Twitter

twitter.com/JPGNonline

 

Visit JPGN.org on your smartphone. Scan this code (QR reader app required) with your phone and be taken directly to the site.