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Non-variceal gastrointestinal bleed in children: surgical experience with emphasis on management challenges

  • Richa LalEmail author
  • Surender K. Yachha
  • Ankur Mandelia
  • Navdeep Dhoat
  • Divya Prakash
  • Moinak Sen Sarma
  • Rajanikant R. Yadav
  • Anshu Srivastava
  • Ujjal Poddar
  • Anu Behari
Original Article

Abstract

Purpose

This exclusively surgical series on pediatric non-variceal gastrointestinal bleed (NVGIB) defines three levels of bleed site and describes etiology, bleed severity, diagnostic algorithm, and surgical management for each bleed site. Management challenges are detailed.

Methods

Patients aged ≤ 18 years treated surgically for NVGIB were analysed.

Results

Bleed site (n = 87) was classified as: upper gastrointestinal bleed (UGIB; n = 11); small bowel bleed (SBB: n = 52); and lower GIB (n = 24). Four etiology-based groups were identified: lesions with ectopic gastric mucosa (EGM; n = 33), tumours (n = 23), ulcers (n = 21), and vascular pathology (n = 8). Bleed severity spectrum was: acute severe bleed (n = 12); subacute overt bleed (n = 59); and occult GIB (n = 16). Preoperative diagnosis was obtained in all UGIB and LGIB lesions. Eighty-two percent of surgical SB lesions were diagnosed preoperatively on Tc99m pertechnetate scan, computed tomography enterography–angiography, and capsule endoscopy; remaining 18% were diagnosed at laparotomy with intra-operative enteroscopy (IOE). Surgical management was tailored to bleed site, severity, and etiology. Indications of IOE and approach to management challenges are detailed.

Conclusions

The commonest site-specific bleed etiologies were duodenal ulcers for UGIB, EGM lesions for SBB, and tumours for LGIB. SBB presented diagnostic challenge. Diagnostic algorithm was tailored to bleed site, age-specific etiology, bleed severity, and associated abdominal/systemic symptoms. Management challenges were acute severe bleed, occult GIB, SBB, obscure GIB, and rare etiologies. IOE has a useful role in SBB management.

Keywords

Non-variceal gastrointestinal bleed Tc99m pertechnetate scan Computed tomography enterography–angiography Capsule endoscopy Intra-operative enteroscopy 

Abbreviations

ATD

Alimentary tract duplication

AVM

Arteriovenous malformation

BTL

Blunt trauma liver

CTEA

Computed tomography enterography–angiography

CTA

Computed tomography angiography

CE

Capsule endoscopy

CD

Crohn’s disease

DU

Duodenal ulcer

DJF

Duodenojejunal flexure

EGD

Esophago-gastro-duodenoscopy

EGM

Ectopic gastric mucosa

FOB

Fecal occult blood

GIB

Gastrointestinal bleed

GEJ

Gastro-esophageal junction

GIST

Gastrointestinal stromal tumour

HAP

Hepatic artery pseudo-aneurysm

IOE

Intra-operative enteroscopy

ICJ

Ileocaecal junction

ICS

Ileo-colonoscopy

JPC

Juvenile polyposis coli

MD

Meckel’s diverticulum

NVGIB

Non-variceal gastrointestinal bleed

PGITL

Primary gastrointestinal tract lymphoma

RPC

Restorative proctocolectomy

SBB

Small bowel bleed

SB

Small bowel

SRUS

Solitary rectal ulcer syndrome

SBE

Small bowel endoscopy

TcPS

Tc99m pertechnetate scan

UGIB

Upper gastrointestinal bleed

USG

Ultrasonography

UC

Ulcerative colitis

VM

Vascular malformation

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Human rights statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study, formal consent is not required.

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Richa Lal
    • 1
    Email author
  • Surender K. Yachha
    • 2
  • Ankur Mandelia
    • 1
  • Navdeep Dhoat
    • 1
  • Divya Prakash
    • 1
  • Moinak Sen Sarma
    • 2
  • Rajanikant R. Yadav
    • 3
  • Anshu Srivastava
    • 2
  • Ujjal Poddar
    • 2
  • Anu Behari
    • 4
  1. 1.Department of Pediatric Surgical SuperspecialtiesSanjay Gandhi Postgraduate Institute of Medical SciencesLucknowIndia
  2. 2.Department of Pediatric GastroenterologySanjay Gandhi Post Graduate Institute of Medical SciencesLucknowIndia
  3. 3.Department of Radio-diagnosisSanjay Gandhi Post Graduate Institute of Medical SciencesLucknowIndia
  4. 4.Department of Surgical GastroenterologySanjay Gandhi Post Graduate Institute of Medical SciencesLucknowIndia

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