Gastrointestinal Bleeding in Children: Current Management, Controversies, and Advances

The role of partial splenic artery embolization in the management of refractory esophageal variceal bleeding due to portal vein thrombosis

BACKGROUND

Gastro-esophageal variceal hemorrhage (GEVH) is one of the major causes of life-threatening gastrointestinal bleeding in children. Medical, endoscopic, angiographic, and surgical interventions can be utilized in treatment. In this case report, we describe partial splenic artery embolization for refractory GEVH due to portal vein thrombosis.

CASE PRESENTATION

A 3-year-old male patient was admitted with abdominal distension. He had been followed up for hepatosplenomegaly for 2 years. The patient's body weight was 15.5 kg (50-75th percentile, 0.69 SDS) and height was 96 cm (50-75th percentile, 0.27 SDS). The general condition was moderate, and the skin appeared pale. The liver was palpable 2 cm, and the spleen was palpable 6 cm below the costal margin. Other system examinations were normal. Laboratory findings included hemoglobin (Hgb) of 7.1 g/dL, hematocrit (Hct) of 24%, white blood cell count of 9800/mm3, platelets of 67000/mm3, and INR of 1.3. Abdominal CT angiography demonstrated a hypodense thrombus at the portal confluence, almost completely occluding the lumen. Endoscopy revealed esophageal varices at the 2 and 7 o'clock positions in the distal esophagus, which became more prominent with insufflation and had red spots on them. Hyperemia was observed in the corpus and antrum of the stomach. Findings were consistent with stage 3 esophageal varices and increased vascularity in the duodenum due to portal vein thrombosis. Medical treatment with a proton pump inhibitor and beta-blocker was initiated. The patient underwent endoscopic band ligation (EBL) three times over 9 months. Despite EBL, the patient presented with GEVH three times during a 1.5-year follow-up. Due to newly developed multiple varices observed on control endoscopy a decision was made to perform splenic artery embolization. Interventional radiology performed selective lower splenic pole embolization. Six months later, the patient underwent another selective embolization. The patient has been followed up for 3 years without GEVH.

CONCLUSIONS

In this case, splenic artery embolization was observed to be an effective, repeatable, and safe treatment method for patients with hypersplenism caused by portal hypertension and refractory esophageal variceal bleeding.

Prehospital Whole Blood Administration for Pediatric Gastrointestinal Hemorrhage: A Case Report

The management of gastrointestinal (GI) hemorrhage in a prehospital setting presents significant challenges, particularly in arresting the hemorrhage and initiating resuscitation. This case report introduces a novel instance of prehospital whole blood transfusion to an 8-year-old male with severe lower GI hemorrhage, marking a shift in prehospital pediatric care. The patient, with no previous significant medical history, presented with acute rectal bleeding, severe hypotension (systolic/diastolic blood pressure [BP] 50/30 mmHg), and tachycardia (148 bpm). Early intervention by Emergency Medical Services (EMS), including the administration of 500 mL (16 mL/kg) of whole blood, led to marked improvement in vital signs (BP 97/64 mmHg and heart rate 93 bpm), physiology, and physical appearance, underscoring the potential effectiveness of prehospital whole blood transfusion in pediatric GI hemorrhage. Upon hospital admission, a Meckel's diverticulum was identified as the bleeding source, and it was successfully surgically resected. The patient's recovery was ultimately favorable, highlighting the importance of rapid, prehospital intervention and the potential role of whole blood transfusion in managing acute pediatric GI hemorrhage. This case supports the notion of advancing EMS protocols to include interventions historically reserved for the hospital setting that may significantly impact patient outcomes from the field.

Efficacy and safety of empiric treatment with omeprazole continuous infusion in critically ill children with gastrointestinal bleeding

Introduction

Gastrointestinal bleeding (GI) is a prevalent condition among pediatric patients, with a reported incidence of 6.4%, often severe enough to require admission to the pediatric intensive care unit (PICU). There are multiple therapies utilized in the management of GI bleeding in pediatrics, among which continuous intravenous (IV) infusion of omeprazole is used off-label without standard pediatric dosing recommendations. Reviewing the current literature reveals a lack of studies assessing the efficacy, safety, and appropriate dosing regimen of continuous omeprazole infusion in children with GI bleeding. This study aimed to evaluate the efficacy and safety of continuous IV omeprazole infusion in comparison to other therapeutic modalities in children.

Methods

This study is a single-center, retrospective chart review of children admitted to the PICU at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. The treatment group included pediatric patients with GI bleeding and receiving omeprazole IV continuous infusion over ≥24 h while the control group included pediatric patients with GI bleeding managed using other therapies. Primary outcomes were the efficacy of omeprazole continuous infusion in stopping GI bleeding, and PICU length of stay (LOS). Secondary outcomes included instances of rebleeding post- therapy discontinuation, transfusion requirements, and the safety of omeprazole continuous infusion.

Results

The study included 81 critically ill pediatric patients, 22 of whom received continuous infusion omeprazole while 59 received other therapies. The results indicated that patients in the control group had a significantly shorter PICU LOS (8 vs. 18.5 days, p < 0.001) and bleeding episode (4 vs. 10.5 days, p < 0.001) than those in the treatment group. However, no significant differences were observed between the two groups regarding secondary outcomes. The treatment group had a significantly lower all-cause mortality rate during hospitalization compared to the control group (16 patients [72.7%] vs. 56 patients [94.9%], respectively, p = 0.005).

Conclusion

Empirical use of omeprazole continuous intravenous infusion in children with GI bleeding was not favorable in terms of shortening PICU LOS and duration of GI bleeding. Our study results provide evidence supporting the safety and tolerability of omeprazole continuous infusion. Additional larger studies are necessary to determine the implication of such results.

Gastrointestinal bleeding in children: diagnostic approach

Different conditions may underlie gastrointestinal bleeding (GIB) in children. The estimated prevalence of GIB in children is 6.4%, with spontaneous resolution in approximately 80% of cases. Nonetheless, the initial approach plays a pivotal role in determining the prognosis. The priority is the stabilization of hemodynamic status, followed by a systematic diagnostic approach. GIB can originate from either upper or lower gastrointestinal tract, leading to a broad differential diagnosis in infants and children. This includes benign and self-limiting disorders, alongside serious conditions necessitating immediate treatment. We performed a nonsystematic review of the literature, in order to describe the variety of conditions responsible for GIB in pediatric patients and to outline diagnostic pathways according to patients' age, suspected site of bleeding and type of bleeding which can help pediatricians in clinical practice. Diagnostic modalities may include esophagogastroduodenoscopy and colonoscopy, abdominal ultrasonography or computed tomography and, when necessary, magnetic resonance imaging. In this review, we critically assess these procedures, emphasizing their respective advantages and limitations concerning specific clinical scenarios.