Non-variceal gastrointestinal bleed in children: surgical experience with emphasis on management challenges
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.
KeywordsNon-variceal gastrointestinal bleed Tc99m pertechnetate scan Computed tomography enterography–angiography Capsule endoscopy Intra-operative enteroscopy
Alimentary tract duplication
Blunt trauma liver
Computed tomography enterography–angiography
Computed tomography angiography
Ectopic gastric mucosa
Fecal occult blood
Gastrointestinal stromal tumour
Hepatic artery pseudo-aneurysm
Juvenile polyposis coli
Non-variceal gastrointestinal bleed
Primary gastrointestinal tract lymphoma
Small bowel bleed
Solitary rectal ulcer syndrome
Small bowel endoscopy
Tc99m pertechnetate scan
Upper gastrointestinal bleed
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.
For this type of study, formal consent is not required.
- 11.Wrenn EL Jr (1962) Tubular duplication of the small intestine. Surgery 52:494–498Google Scholar
- 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.Vahedian J, Keramati MR, Hashemi MH, Vasigh M (2010) Duodenal kissing ulcer: report of a case. Govaresh 15:243–246Google Scholar
- 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
- 19.Young AE (1988) Arteriovenous malformations. In: Mulliken JB, Young AE (eds) Vascular birth marks: hemangiomas & malformations. WB Saunders, Philadelphia, pp 381–399Google Scholar
- 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.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
- 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
- 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.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