IMAGE OF THE MONTH An Unexpected Cause of Upper Gastrointestinal Bleeding in a Child Q7
Amanda Ricciuto,*,‡ Catharine M. Walsh,*,‡,§,k and Peter C. Church* *Division of Paediatric Gastroenterology, Hepatology and Nutrition, ‡Department of Paediatrics, §Learning Institute, kResearch Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
print & web 4C=FPO
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e present an 11-year-old boy who was transferred to our institution after an upper gastrointestinal bleed. He initially presented to a community hospital after several episodes of hematemesis and melena, preceded by 2 days of epigastric pain. The child was previously well, except for pharyngitis treated with antibiotics a few weeks prior. There was no history of nonsteroidal anti-inflammatory use. On presentation, he was in shock, with a lactate level of 10 mmol/L, a white blood cell count of 40 109/L, a hemoglobin level of 170 g/L, and a glucose level of 23 mmol/L. He was fluid-resuscitated, started on antibiotics, and transferred to our tertiary center. On arrival, he continued to report abdominal pain and nausea. Vital signs were stable and the physical examination showed only abdominal tenderness, primarily epigastric, without peritoneal signs. The hemoglobin level decreased to 105 g/L over 24 hours before stabilizing. The lactate level, glucose level, and white blood cell count normalized over 3 to 4 days. Other notable laboratory findings included hypoalbuminemia (23 g/L), and increased urea level (8.7 mmol/L), amylase level (167 U/L), lipase level (121 U/L), C-reactive protein level (76 mg/L), and erythrocyte sedimentation rate (16 mm/h). Liver enzyme levels, bilirubin level, and coagulation factors were normal. Stool was negative for gastrointestinal pathogens. An abdominal ultrasound showed mild wall
W
thickening of a small-bowel loop in the left flank, but otherwise was normal. Upper endoscopy showed esophagitis with small esophageal erosions and mild gastric erythema, whereas in the duodenum there was diffuse erythema, of a violaceous hue, oozing in patches. This was more pronounced in the second part of the duodenum where a thin mucosal bridge also was observed (Figure A). Histopathologic examination showed mild to moderate chronic active esophagitis, chronic inactive gastritis (negative for Helicobacter pylori), and mild to moderate chronic active duodenitis with moderate villous blunting, without intraepithelial lymphocytosis (Figure B, arrowhead indicates intraepithelial neutrophils). Sigmoidoscopy was normal. Tissue transglutaminase, antineutrophil cytoplasmic antibody, and anti–Saccharomyces cerevisiae antibody were negative, antinuclear antibody was weakly positive (1/40), and C3/C4 were normal. Two days after transfer, the patient developed palpable purpura on his lower extremities and buttocks, as well as microscopic hematuria, trace proteinuria, and knee pain with peri-articular swelling. A skin biopsy showed leukocytoclastic vasculitis and immunofluorescence showed the presence of IgA (Figure C), IgG, and C3 (not shown), confirming the diagnosis of Henoch–Schönlein purpura (HSP). Given the patient’s persistent abdominal pain, steroids were initiated at 1 mg/kg/d, with prompt improvement.
Clinical Gastroenterology and Hepatology 2015;-:-–SCO 5.2.0 DTD YJCGH54259_proof 1 June 2015 3:04 pm ce DVC
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Q6
Systemic vasculitis is an important entity to consider in the differential for gastrointestinal hemorrhage. This case highlights the challenge in diagnosing HSP, the most common systemic vasculitis in children, when abdominal pain precedes the characteristic rash, as occurs in 12% to 19% of cases.1 The second portion of the duodenum characteristically is involved,2 with highly variable endoscopic findings, ranging from hyperemia to severe ulcerations. However, mucosal bridges, as described earlier, have not been reported in HSP. Histologic findings may be nonspecific but may show pathognomonic leukocytoclastic vasculitis, particularly if more severe, ischemic lesions are sampled.2 Steroids may be helpful to hasten the resolution of severe gastrointestinal symptoms.2,3
References 1.
Ebert EC. Gastrointestinal manifestations of Henoch-Schonlein Purpura. Dig Dis Sci 2008;53:2011–2019.
2.
Nam EJ, Kim GW, Kang JW, et al. Gastrointestinal bleeding in adult patients with Henoch-Schonlein purpura. Endoscopy 2014;46:981–986. Ronkainen J, Koskimies O, Ala-Houhala M, et al. Early prednisone therapy in Henoch-Schonlein purpura: a randomized, doubleblind, placebo-controlled trial. J Pediatr 2006;149:241–247.
3.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.04.019
2 SCO 5.2.0 DTD YJCGH54259_proof 1 June 2015 3:04 pm ce DVC
Q1
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Amanda Ricciuto,*,‡ Catharine M. Walsh,*,‡,§,k and Peter C. Church* *Division of Paediatric Gastroenterology, Hepatology and Nutrition, ‡Department of Paediatrics, §Learning Institute, kResearch Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
print & web 4C=FPO
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
Q2 Q3 Q4
Q5
e present an 11-year-old boy who was transferred to our institution after an upper gastrointestinal bleed. He initially presented to a community hospital after several episodes of hematemesis and melena, preceded by 2 days of epigastric pain. The child was previously well, except for pharyngitis treated with antibiotics a few weeks prior. There was no history of nonsteroidal anti-inflammatory use. On presentation, he was in shock, with a lactate level of 10 mmol/L, a white blood cell count of 40 109/L, a hemoglobin level of 170 g/L, and a glucose level of 23 mmol/L. He was fluid-resuscitated, started on antibiotics, and transferred to our tertiary center. On arrival, he continued to report abdominal pain and nausea. Vital signs were stable and the physical examination showed only abdominal tenderness, primarily epigastric, without peritoneal signs. The hemoglobin level decreased to 105 g/L over 24 hours before stabilizing. The lactate level, glucose level, and white blood cell count normalized over 3 to 4 days. Other notable laboratory findings included hypoalbuminemia (23 g/L), and increased urea level (8.7 mmol/L), amylase level (167 U/L), lipase level (121 U/L), C-reactive protein level (76 mg/L), and erythrocyte sedimentation rate (16 mm/h). Liver enzyme levels, bilirubin level, and coagulation factors were normal. Stool was negative for gastrointestinal pathogens. An abdominal ultrasound showed mild wall
W
thickening of a small-bowel loop in the left flank, but otherwise was normal. Upper endoscopy showed esophagitis with small esophageal erosions and mild gastric erythema, whereas in the duodenum there was diffuse erythema, of a violaceous hue, oozing in patches. This was more pronounced in the second part of the duodenum where a thin mucosal bridge also was observed (Figure A). Histopathologic examination showed mild to moderate chronic active esophagitis, chronic inactive gastritis (negative for Helicobacter pylori), and mild to moderate chronic active duodenitis with moderate villous blunting, without intraepithelial lymphocytosis (Figure B, arrowhead indicates intraepithelial neutrophils). Sigmoidoscopy was normal. Tissue transglutaminase, antineutrophil cytoplasmic antibody, and anti–Saccharomyces cerevisiae antibody were negative, antinuclear antibody was weakly positive (1/40), and C3/C4 were normal. Two days after transfer, the patient developed palpable purpura on his lower extremities and buttocks, as well as microscopic hematuria, trace proteinuria, and knee pain with peri-articular swelling. A skin biopsy showed leukocytoclastic vasculitis and immunofluorescence showed the presence of IgA (Figure C), IgG, and C3 (not shown), confirming the diagnosis of Henoch–Schönlein purpura (HSP). Given the patient’s persistent abdominal pain, steroids were initiated at 1 mg/kg/d, with prompt improvement.
Clinical Gastroenterology and Hepatology 2015;-:-–SCO 5.2.0 DTD YJCGH54259_proof 1 June 2015 3:04 pm ce DVC
53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104
IMAGE OF THE MONTH, continued 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129
Q6
Systemic vasculitis is an important entity to consider in the differential for gastrointestinal hemorrhage. This case highlights the challenge in diagnosing HSP, the most common systemic vasculitis in children, when abdominal pain precedes the characteristic rash, as occurs in 12% to 19% of cases.1 The second portion of the duodenum characteristically is involved,2 with highly variable endoscopic findings, ranging from hyperemia to severe ulcerations. However, mucosal bridges, as described earlier, have not been reported in HSP. Histologic findings may be nonspecific but may show pathognomonic leukocytoclastic vasculitis, particularly if more severe, ischemic lesions are sampled.2 Steroids may be helpful to hasten the resolution of severe gastrointestinal symptoms.2,3
References 1.
Ebert EC. Gastrointestinal manifestations of Henoch-Schonlein Purpura. Dig Dis Sci 2008;53:2011–2019.
2.
Nam EJ, Kim GW, Kang JW, et al. Gastrointestinal bleeding in adult patients with Henoch-Schonlein purpura. Endoscopy 2014;46:981–986. Ronkainen J, Koskimies O, Ala-Houhala M, et al. Early prednisone therapy in Henoch-Schonlein purpura: a randomized, doubleblind, placebo-controlled trial. J Pediatr 2006;149:241–247.
3.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.04.019
2 SCO 5.2.0 DTD YJCGH54259_proof 1 June 2015 3:04 pm ce DVC
Q1
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