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 Case References EGD # 1Final Hemostasis Diagnosis EGD # 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 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. Hospital course Ulcer with eschar and another with a clot and a cherry red spot- Epinephrine injected EGD#3 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. 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 Your references here Cardia of stomach and pylorus Medical management continued. 2 days later patient has massive hematemesis. Following day: patient had another episode of UGIB 2 gram drop in Hb. EGD and cautery with Gold heater probe Pre Discharge EGD Hospital summary Dieulafoy’s lesion cont’d 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.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.Life-threatening haemorrhage from a gastric Dieulafoy lesion in a child with haemophilia.Life-threatening haemorrhage from a gastric Dieulafoy lesion in a child with haemophilia. 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. Dieulafoy lesion in a one-year-old child. Dieulafoy lesion in a one-year-old child. 3. Sweerts M, Nicholson AG, Goldstraw P, Corrin B. Dieulafoy's disease of the bronchus. Thorax. 1995 Jun;50(6):697-8. Dieulafoy's disease of the bronchus.Dieulafoy's disease of the bronchus. 4. Anireddy D, Timberlake G, Seibert D. Dieulafoy's lesion of the esophagus. Gastrointest Endosc. 1993 Jul-Aug;39(4):604. Dieulafoy's lesion of the esophagus.Dieulafoy's lesion of the esophagus. 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. Bleeding jejunal Dieulafoy pseudopolyp: capsule endoscopic detection and laparoscopic-assisted resection.Bleeding jejunal Dieulafoy pseudopolyp: capsule endoscopic detection and laparoscopic-assisted resection. 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. Endoscopic band ligation of a Dieulafoy lesion in the small intestine of a child.Endoscopic band ligation of a Dieulafoy lesion in the small intestine of a child. 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. Endoscopic management of rectal Dieulafoy-like lesions: a case series and review of literature.Endoscopic management of rectal Dieulafoy-like lesions: a case series and review of literature. 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. Dieulafoy lesion: endoscopic and surgical management.Dieulafoy lesion: endoscopic and surgical management. 9. Driver CP, Bruce J. An unusual cause of massive gastric bleeding in a child. J Pediatr Surg. 1997 Dec;32(12):1749-50. An unusual cause of massive gastric bleeding in a child.An unusual cause of massive gastric bleeding in a child. 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. An unusual cause for massive upper gastrointestinal bleeding in children: Dieulafoy's lesion.An unusual cause for massive upper gastrointestinal bleeding in children: Dieulafoy's lesion. Treatment Dieulafoy’s lesion Conclusion