8/19/2019 Severe Erosive Hemorrhagic Gastritis in a.1
1/1Copyright 2012 by ESPGHAN and NASPGHAN Unauthorized
reproduction of this article is prohibited
Severe Erosive Hemorrhagic Gastritis in a Pediatric Patient
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 physicalexamination 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 visiblevessels. (Fig. 1) Argon plasma coagulation to
treat diffuse disease was not available. Bipolar cautery was
applied. Initial biopsies showed focal active inflammationand
regenerative changes (Fig. 2). Gastrin level was normal and
cytomegalovirus, Epstein-Barr virus, herpes simplex virus,
adenovirus, Helicobacter pylori testingwas 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, achievinghemostasis, 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). Thereare limited pediatric
reports on the causes of such severe erosive and hemorrhagic
gastritis.This patient did not have anoncologic 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.
Submitted by:Joel Friedlander, ySamir Shehab,
zMarvin Harrison, and §Zili Zhang
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, and § Department of
Pediatrics, Division of Pediatric G astroenterology, 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:
[email protected]).
The authors report no conflicts of interest.
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 descriptionof no more
than 200 words should accompanythe images. Submissionsareto be made
online at www.jpgn.org, and will undergo peer review by
members of the NASPGHAN Endoscopy and Procedures Committee, as well
as by the Journal.
REFERENCES
1. Soylu AR, Buyukasik Y, Cetiner D, et al. Overt
gastrointestinal bleeding in haematologic neoplasms. Dig Liver
Dis 2005;37:917– 22.
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;31:1446–51.
3. Hokama A, Taira K, Yamamoto Y, et al. Cytomegalovirus
gastritis. World J Gastrointest Endosc
2010;2:379–80.
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 multicent er study.
Eur J Gastroenterol Hepatol 2010;22:1174– 81.
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– 42.
Copyright # 2012 by European Society for Pediatric
Gastroenterology, Hepatology, and Nutrition and North American
Society for Pediatric Gastroenterology,
Hepatology, and Nutrition
DOI: 10.1097/MPG.0b013e318246deca
FIGURE 1. Diffuse gastriculceration of antrum, body,and
fundus with numerousvisible vessels.
FIGURE 2. Mucosal gastricbiopsies with focal
activeinflammation with regene-rative changes.
FIGURE 3. Actively bleed-ing ulceration of gastric
fun-dus pre- and posttherapy.
FIGURE 4. Full-thicknessgastric biopsy with
severeulceration, necrosis, inflam-mation, thrombosis,
andhemorrhage.
IMAGE OF THE MONTH
JPGN Volume 55, Number 2, August 2012
119
mailto:[email protected]://www.jpgn.org/http://www.jpgn.org/http://www.jpgn.org/http://www.jpgn.org/http://dx.doi.org/10.1097/MPG.0b013e318246decahttp://dx.doi.org/10.1097/MPG.0b013e318246decahttp://www.jpgn.org/mailto:[email protected]
