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



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.


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


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.


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.


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



Alimentary tract duplication


Arteriovenous malformation


Blunt trauma liver


Computed tomography enterography–angiography


Computed tomography angiography


Capsule endoscopy


Crohn’s disease


Duodenal ulcer


Duodenojejunal flexure




Ectopic gastric mucosa


Fecal occult blood


Gastrointestinal bleed


Gastro-esophageal junction


Gastrointestinal stromal tumour


Hepatic artery pseudo-aneurysm


Intra-operative enteroscopy


Ileocaecal junction




Juvenile polyposis coli


Meckel’s diverticulum


Non-variceal gastrointestinal bleed


Primary gastrointestinal tract lymphoma


Restorative proctocolectomy


Small bowel bleed


Small bowel


Solitary rectal ulcer syndrome


Small bowel endoscopy


Tc99m pertechnetate scan


Upper gastrointestinal bleed




Ulcerative colitis


Vascular malformation


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.


  1. 1.
    Gerson LB, Fidler JF, Cave DR, Leighton JA (2015) ACG clinical guideline: diagnosis & management of small bowel bleeding. Am J Gastroenterol 110:1265–1287CrossRefGoogle Scholar
  2. 2.
    Lin S, Rockey DC (2005) Obscure Gastrointestinal bleeding. Gastroenterol Clin N Am 34:679–698CrossRefGoogle Scholar
  3. 3.
    Singhi S, Jain P, Jayashree M, Lal S (2013) Approach to a child with upper gastrointestinal bleeding. Indian J Pediatr 80:326–333CrossRefGoogle Scholar
  4. 4.
    Balachnadran B, Singhi S (2013) Emergency management of lower gastrointestinal bleed in children. Indian J Pediatr 80:219–225CrossRefGoogle Scholar
  5. 5.
    Dillon PA, Warner BW (2012) Gastrointestinal bleeding. In: Coran AG, Adzick NS, Krummel TM (eds) Pediatric surgery, 7th edn. Elseviers Saunders, Philadelphia, pp 1147–1154CrossRefGoogle Scholar
  6. 6.
    Brown RL, Azizkhan RG (1999) Gastrointestinal bleeding in infants and children: Meckel’s diverticulum and intestinal duplication. Semin Pediatr Surg 8:202–209CrossRefGoogle Scholar
  7. 7.
    Carey EJ, Fleischer DF (2005) Investigation of the small bowel in gastrointestinal bleeding. Gastroenterol Clin N Am 34:719–734CrossRefGoogle Scholar
  8. 8.
    Racadio JM, Agha Ayad KM, Johnson ND, Warner BW (1999) Imaging and radiological interventional techniques for gastrointestinal bleeding in children. Semin Pediatr Surg 8:181–192CrossRefGoogle Scholar
  9. 9.
    Pandey S, Srivastava A, Lal R, Yachha SK, Poddar U (2014) Enteric duplication cysts in children: a target in algorithm for evaluation of lower gastrointestinal bleeding. Indian J Gastroenterol 33:285–288CrossRefGoogle Scholar
  10. 10.
    Norris RW, Brereton RJ, Wright VM, Cudmore RE (1986) A new surgical approach to duplications of intestine. J Pediatr Surg 21:167–170CrossRefGoogle Scholar
  11. 11.
    Wrenn EL Jr (1962) Tubular duplication of the small intestine. Surgery 52:494–498Google Scholar
  12. 12.
    Edwards AJ, Kollenberg SJ, Brandt ML, Wesson DE, Nuchtern JG, Minifee PK, Cass DL (2005) Surgery for peptic ulcer disease in children in the post histamine 2-blocker era. J Pediatr Surg 40:850–854CrossRefGoogle Scholar
  13. 13.
    Hosseini SV, Sabet B, Amini M (2008) Surgical management of combined perforated & bleeding duodenal ulcer. Iran Red Crescent Med J 10:30–33Google Scholar
  14. 14.
    Vahedian J, Keramati MR, Hashemi MH, Vasigh M (2010) Duodenal kissing ulcer: report of a case. Govaresh 15:243–246Google Scholar
  15. 15.
    Rice HE, Chuang E (1999) Current management of pediatric inflammatory bowel disease. Semin Pediatr Surg 8:221–228CrossRefGoogle Scholar
  16. 16.
    Thandassery RB, Sharma M, Abdelmola A, Derbala MFM, Al Kaabi SR (2014) Uncommon gastrointestinal complications of enteric fever in a non-endemic country. Qatar Med J 7:46–49Google Scholar
  17. 17.
    Watanabe T, Kudo M, Kayaba M, Shirane H, Tomita S, Orino A, Todo A, Chiba J (1999) Massive rectal bleeding due to ileal tuberculosis. J Gastroenterol 34:525–529CrossRefGoogle Scholar
  18. 18.
    Kela M, Agrawal A, Sharma R, Agarwal R, Agarwal VB (2009) Ileal tuberculosis presenting as a case of massive rectal bleeding. Clin Exp Gastroenteol 2:129–131CrossRefGoogle Scholar
  19. 19.
    Young AE (1988) Arteriovenous malformations. In: Mulliken JB, Young AE (eds) Vascular birth marks: hemangiomas & malformations. WB Saunders, Philadelphia, pp 381–399Google Scholar
  20. 20.
    Kalmar PI, Petnehazy T, Weipeiner U, Beer M, Hauer AC, Till H, Riccabona M (2014) Large, segmental circular vascular malformation of the small intestine: unusual presentation in a child. BMC Pediatr 14:55–58CrossRefGoogle Scholar
  21. 21.
    Bezerra KB, Junior EAB, de Sousa Pereira NC, Da Costa FA (2012) Gastric arteriovenous malformation: treatment by embolization. Radiol Bras 45:126–128CrossRefGoogle Scholar
  22. 22.
    Elazary R, Verstanding A, Rivkind AI, Almogy G (2008) Gastric arterio-venous malformation emerging from splenic artery. World J Gastroenterol 14:4091–4092CrossRefGoogle Scholar
  23. 23.
    Lee YJ, Hwang JY, Cho TH, Kim YW, Kim TU, Shin DH (2016) A long segmental vascular malformation in the small bowel presenting with gastrointestinal bleeding in a preschool child. Iran J Radiol 13:e29260Google Scholar
  24. 24.
    Handra-Luca A, Montgomery E (2011) Vascular malformations & hemoangiolymphangiomas of the gastrointestinal tract: morphological features & clinical impact. Int J Clin Exp Pathol 4:430–443Google Scholar
  25. 25.
    Notrica DM, Eubanks JW, Tuggle DW, Maxson RT, Letton RW, Garcia NM et al (2015) Nonoperative management of blunt liver and spleen injury in children: evaluation of the ATOMAC guideline using GRADE. J Trauma Acute Care Surg 79:683–693CrossRefGoogle Scholar
  26. 26.
    Saad NEA, Saad WEA, Davies MG, Waldman DL, Fultz PJ, Rubens DJ (2005) Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics 25:S173–S189CrossRefGoogle Scholar
  27. 27.
    Francisco LE, Asunción LC, Antonio CA, Ricardo RC, Manuel RP, Caridad MH (2010) Post-traumatic hepatic artery pseudoaneurysm treated with endovascular embolization and thrombin injection. World J Hepatol 2:87–90CrossRefGoogle Scholar
  28. 28.
    Marynissen T, Maleux G, Heye S, Vaninbroukx J, Laleman W, Cassiman D et al (2010) Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure: case series and review of the literature. Eur J Gastroenterol Hepatol 24:905–909CrossRefGoogle Scholar
  29. 29.
    Hook S, Spicer R, Williams J, Grier D, Lowis S, Foot A, Sergi C (2003) Severe anemia in a 25-day-old infant due to gastric teratoma with focal neuroblastoma. Am J Perinatol 20:233–237CrossRefGoogle Scholar
  30. 30.
    Hirugade ST, Deshpande AV, Talpallikar MC, Borwankar SS (2001) Gastric teratoma: a rare cause of gastrointestinal bleeding. Indian J Gastroenterol 20:158–159Google Scholar
  31. 31.
    Kim SH, Cho YH, Kim HY, Lee YJ, Park JH (2015) Mature cystic gastric teratoma in an infant: a case presenting with gastrointestinal bleeding. J Korean Assoc Pediatr Surg 21:42–45CrossRefGoogle Scholar
  32. 32.
    Srivastav PK, Jaiman R, Gangopadhyaya AN, Gupta DK (2017) Gastric teratoma presenting as gastric outlet obstruction and malaena: report of a rare case. Indian J Surg 79:64–66CrossRefGoogle Scholar
  33. 33.
    Zhang KR, Jia HM (2009) Primary non-Hodgkin’s lymphoma of the sigmoid colon in a child. Am J Surg 197:e11–e12CrossRefGoogle Scholar
  34. 34.
    Veerabhadra R, Krishna Kumar G, Bibekanand J, Bikash Kumar N, Kumaravel S, Bhawana B, Biswajit D (2018) Bowel lymphoma in children: management and outcome. Indian J Med Paediatr Oncol 39:184–187CrossRefGoogle Scholar
  35. 35.
    Kassira N, Pedroso FE, Cheung MC, Koniaris LG, Sola JE (2011) Primary gastrointestinal tract lymphoma in the pediatric patient: review of 265 patients from the SEER registry. J Pediatr Surg 46:1956–1964CrossRefGoogle Scholar
  36. 36.
    Cianci P, Luini C, Marinoni M, Nespoli L, Salvatoni A, Salvatore S (2017) Pediatric GIST presenting as anemia. Pediatr Hematol Oncol 34:343–347CrossRefGoogle Scholar
  37. 37.
    Lima M, Gargano T, Ruggeri G, Pession A, Mariotto A, Maffi M (2015) Laparoscopic resection of a rare gastrointestinal stromal tumor in children. Springerplus 10:73CrossRefGoogle Scholar
  38. 38.
    Alvarado-Cabrero García-Robles B, Medrano-Guzmán R, Hernández-Hoyos S, Alderete-Vázquez G (2009) Gastrointestinal stromal tumors in the pediatric population. Report of two cases and a review of the literature. Cir Cir 77:135–140Google Scholar
  39. 39.
    Miettinen M, Lasota J, Sobin LH (2005) Gastrointestinal stromal tumors of the stomach in children and young adults: a clinicopathologic, immunohistochemical, and molecular genetic study of 44 cases with long-term follow-up and review of the literature. Am J Surg Pathol 29:1373–1381CrossRefGoogle Scholar

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

Personalised recommendations