Downloaded from http://adc.bmj.com/ on July 21, 2015 - Published by group.bmj.com
ADC Online First, published on July 10, 2015 as 10.1136/archdischild-2015-308749 Images in paediatrics
‘Watermelon stomach’ in a 3-year-old: an unusual cause of upper gastrointestinal bleeding in a child A 3-year-old girl with spina bifida presented with persistent upper gastrointestinal bleeding. Endoscopy demonstrated dilated and tortuous vasculature within the longitudinal folds of the gastric antrum, characteristic of gastric antral vascular ectasia (GAVE) (figure 1).1 Known from its appearance as ‘watermelon stomach’, GAVE has been recognised increasingly as a cause of gastrointestinal blood loss in the adult population, accounting for up to 4% of non-variceal cases.1 To our knowledge, GAVE has been previously described in a child only once, classically being a disease of elderly women.1 2 The pathophysiological changes leading to GAVE are not fully explained, but the disease is often associated with chronic illnesses such as hepatic cirrhosis, autoimmune connective tissue disease and chronic renal failure.3 Histologically, GAVE demonstrates superficial fibromuscular hyperplasia of the antral
mucosa with capillary ectasia and thrombosis in the lamina propria.3 Our patient has a gastrostomy in situ with a transpyloric feeding tube (PEG-J). This was inserted some time prior to commencement of bleeding due to persistent oral feeding difficulty and vomiting. GAVE was not apparent at endoscopy before and soon after insertion of the PEG-J prior to onset of bleeding. The patient has required blood transfusion, and conservative management with acid suppression (omeprazole) has reduced bleeding. Argon photocoagulation therapy may be used as treatment, while endoscopic banding can be considered a second-line approach. Pharmacological options, such as tranexamic acid and oestrogen therapy, stem from case report evidence alone. Surgical antrectomy should be reserved for resistant cases as it is associated with high mortality.1 J Ducey,1 J Puntis,2 M Powis1 1
Department of Paediatric Surgery, Leeds General Infirmary, Leeds, UK Department of Paediatric Gastroenterology, Leeds General Infirmary, Leeds, UK
2
Correspondence to Dr J Ducey, Department of Paediatric Surgery, C Floor, Clarendon Wing, Leeds General Infirmary, Leeds LS1 3EX, UK; [email protected] Contributors JD performed the literature review and wrote the first and final drafts of the manuscript. JP contributed to the writing of the manuscript and provided clinical input. MP was the operating surgeon at endoscopy, contributed to writing of the manuscript and provided clinical input. Funding None. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. To cite Ducey J, Puntis J, Powis M. Arch Dis Child Published Online First: [ please include Day Month Year] doi:10.1136/archdischild-2015-308749 Received 19 April 2015 Revised 15 June 2015 Accepted 19 June 2015 Arch Dis Child 2015;0:1. doi:10.1136/archdischild-2015-308749
REFERENCES 1 2
3
Sellinger CP, Yang SA. Gastric antral vascular ectasia (GAVE): an update on clinical presentation, pathophysiology and treatment. Digestion 2008;77:131–7. Kuroiwa Y, Suzuki N, Mizue N, et al. Gastric antral vascular ectasia in 2-year-old girl undergoing unrelated cord blood stem cell transplantation. Paediatr Transplant 2005;9:788–91. Novitsky YW, Kercher KW, Czerniach DR, et al. Watermelon stomach: pathophysiology, diagnosis, and management. J Gastrointest Surg 2003;7:652–61.
Figure 1 View of the gastric antrum at endoscopy with dilated and tortuous vasculature visible within the longitudinal folds of the stomach wall (features consistent with gastric antral vascular ectasia). Gastrostomy in situ with a transpyloric feeding tube (PEG-J).
Ducey J, et al. Arch Dis Child Month 2015 Vol 0 No 0
1
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.
Downloaded from http://adc.bmj.com/ on July 21, 2015 - Published by group.bmj.com
'Watermelon stomach' in a 3-year-old: an unusual cause of upper gastrointestinal bleeding in a child J Ducey, J Puntis and M Powis Arch Dis Child published online July 10, 2015
Updated information and services can be found at: http://adc.bmj.com/content/early/2015/07/10/archdischild-2015-30874 9
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References
This article cites 3 articles, 0 of which you can access for free at: http://adc.bmj.com/content/early/2015/07/10/archdischild-2015-30874 9#BIBL
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Articles on similar topics can be found in the following collections Stomach and duodenum (54) Surgery (263) Surgical diagnostic tests (251) Competing interests (ethics) (159) Contraception (26) Drugs: endocrine system (112) Epidemiologic studies (1682) GI bleeding (19) Journalology (211) Liver disease (171) Oncology (716) Renal medicine (261) Reproductive medicine (896) Rheumatology (465) Sexual health (326) Urology (424)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
ADC Online First, published on July 10, 2015 as 10.1136/archdischild-2015-308749 Images in paediatrics
‘Watermelon stomach’ in a 3-year-old: an unusual cause of upper gastrointestinal bleeding in a child A 3-year-old girl with spina bifida presented with persistent upper gastrointestinal bleeding. Endoscopy demonstrated dilated and tortuous vasculature within the longitudinal folds of the gastric antrum, characteristic of gastric antral vascular ectasia (GAVE) (figure 1).1 Known from its appearance as ‘watermelon stomach’, GAVE has been recognised increasingly as a cause of gastrointestinal blood loss in the adult population, accounting for up to 4% of non-variceal cases.1 To our knowledge, GAVE has been previously described in a child only once, classically being a disease of elderly women.1 2 The pathophysiological changes leading to GAVE are not fully explained, but the disease is often associated with chronic illnesses such as hepatic cirrhosis, autoimmune connective tissue disease and chronic renal failure.3 Histologically, GAVE demonstrates superficial fibromuscular hyperplasia of the antral
mucosa with capillary ectasia and thrombosis in the lamina propria.3 Our patient has a gastrostomy in situ with a transpyloric feeding tube (PEG-J). This was inserted some time prior to commencement of bleeding due to persistent oral feeding difficulty and vomiting. GAVE was not apparent at endoscopy before and soon after insertion of the PEG-J prior to onset of bleeding. The patient has required blood transfusion, and conservative management with acid suppression (omeprazole) has reduced bleeding. Argon photocoagulation therapy may be used as treatment, while endoscopic banding can be considered a second-line approach. Pharmacological options, such as tranexamic acid and oestrogen therapy, stem from case report evidence alone. Surgical antrectomy should be reserved for resistant cases as it is associated with high mortality.1 J Ducey,1 J Puntis,2 M Powis1 1
Department of Paediatric Surgery, Leeds General Infirmary, Leeds, UK Department of Paediatric Gastroenterology, Leeds General Infirmary, Leeds, UK
2
Correspondence to Dr J Ducey, Department of Paediatric Surgery, C Floor, Clarendon Wing, Leeds General Infirmary, Leeds LS1 3EX, UK; [email protected] Contributors JD performed the literature review and wrote the first and final drafts of the manuscript. JP contributed to the writing of the manuscript and provided clinical input. MP was the operating surgeon at endoscopy, contributed to writing of the manuscript and provided clinical input. Funding None. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. To cite Ducey J, Puntis J, Powis M. Arch Dis Child Published Online First: [ please include Day Month Year] doi:10.1136/archdischild-2015-308749 Received 19 April 2015 Revised 15 June 2015 Accepted 19 June 2015 Arch Dis Child 2015;0:1. doi:10.1136/archdischild-2015-308749
REFERENCES 1 2
3
Sellinger CP, Yang SA. Gastric antral vascular ectasia (GAVE): an update on clinical presentation, pathophysiology and treatment. Digestion 2008;77:131–7. Kuroiwa Y, Suzuki N, Mizue N, et al. Gastric antral vascular ectasia in 2-year-old girl undergoing unrelated cord blood stem cell transplantation. Paediatr Transplant 2005;9:788–91. Novitsky YW, Kercher KW, Czerniach DR, et al. Watermelon stomach: pathophysiology, diagnosis, and management. J Gastrointest Surg 2003;7:652–61.
Figure 1 View of the gastric antrum at endoscopy with dilated and tortuous vasculature visible within the longitudinal folds of the stomach wall (features consistent with gastric antral vascular ectasia). Gastrostomy in situ with a transpyloric feeding tube (PEG-J).
Ducey J, et al. Arch Dis Child Month 2015 Vol 0 No 0
1
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.
Downloaded from http://adc.bmj.com/ on July 21, 2015 - Published by group.bmj.com
'Watermelon stomach' in a 3-year-old: an unusual cause of upper gastrointestinal bleeding in a child J Ducey, J Puntis and M Powis Arch Dis Child published online July 10, 2015
Updated information and services can be found at: http://adc.bmj.com/content/early/2015/07/10/archdischild-2015-30874 9
These include:
References
This article cites 3 articles, 0 of which you can access for free at: http://adc.bmj.com/content/early/2015/07/10/archdischild-2015-30874 9#BIBL
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Topic Collections
Articles on similar topics can be found in the following collections Stomach and duodenum (54) Surgery (263) Surgical diagnostic tests (251) Competing interests (ethics) (159) Contraception (26) Drugs: endocrine system (112) Epidemiologic studies (1682) GI bleeding (19) Journalology (211) Liver disease (171) Oncology (716) Renal medicine (261) Reproductive medicine (896) Rheumatology (465) Sexual health (326) Urology (424)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
