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.
1. Soylu AR, Buyukasik Y, Cetiner D, et al. Overt gastrointestinal bleeding in haematologic neoplasms. Dig Liver Dis
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
3. Hokama A, Taira K, Yamamoto Y, et al. Cytomegalovirus gastritis. World J Gastrointest Endosc
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
5. Nithiwathanapong C, Reungrongrat S, Ukarapol N. Prevalence and risk factors of stress-induced gastrointestinal bleeding in critically ill children. World J Gastroenterol: WJG