IMAGE

OF THE

MONTH

Severe Erosive Hemorrhagic Gastritis in a Pediatric Patient

FIGURE 1. Diffuse gastric

ulceration of antrum, body,
and fundus with numerous
visible vessels.

FIGURE 2. Mucosal gastric

biopsies with focal active
inflammation with regenerative changes.
FIGURE 3. Actively bleeding ulceration of gastric fundus pre- and posttherapy.

FIGURE 4. Full-thickness
gastric biopsy with severe
ulceration, necrosis, inflammation, thrombosis, and
hemorrhage.

An 11-year-old-Hispanic boy with relapsed acute lymphocytic leukemia presented with hematemesis and melena 1 week after admission for sepsis and
rhabdomyolysis. He had presyncope and presented to an outside hospital with hemoglobin 8.4 mg/dL. His recent chemotherapeutic experimental protocol included
epratuzumab, vincristine, PEG-asparaginase, prednisone, and intrathecal methotrexate. He denied NSAID use and was on ranitidine prophylaxis. His physical
examination was remarkable for a pale, cushingnoid male with hepatomegaly (14 cm) and without splenomegaly. Rectal examination demonstrated melanotic stool.
The balance of the examination was unremarkable.
The patient underwent esophagogastroduodenoscopy once he was hemodynamically stable. The gastric mucosa was diffusely ulcerated, with numerous visible
vessels. (Fig. 1) Argon plasma coagulation to treat diffuse disease was not available. Bipolar cautery was applied. Initial biopsies showed focal active inflammation
and regenerative changes (Fig. 2). Gastrin level was normal and cytomegalovirus, Epstein-Barr virus, herpes simplex virus, adenovirus, Helicobacter pylori testing
was negative. Despite a pantoprazole drip, bleeding recurred in a now deep ulcer within the gastric fundus (Fig. 3), which required epinephrine injection, bipolar
cautery, and endoscopic clipping. Bleeding subsequently recurred at requiring massive transfusion protocol. Interventional radiology was unsuccessful, achieving
hemostasis, and a partial gastric resection with use of factor VIIa was performed. Pathology showed severe ulceration, necrosis, hemorrhage, inflammation, and
thrombosis (Fig. 4). No leukemic infiltrate was found. Subsequently, the patient did well.
Severe gastrointestinal bleeding from severe hemorrhagic and erosive gastritis in pediatrics is rarely reported. The cause here is likely multifactorial (1). There
are limited pediatric reports on the causes of such severe erosive and hemorrhagic gastritis. This patient did not have an oncologic infiltrate, viral infection, ZollingerEllison syndrome, or report NSAID use (25). We suspect that the cause was chemotherapeutics and recent sepsis with Cushing ulcer.
Submitted by:


Joel Friedlander, ySamir Shehab, zMarvin Harrison, and Zili Zhang


Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Childrens Hospital of Colorado,
University of Colorado Health Sciences Center, Aurora, CO, {Northwest Permanente, {Department of Surgery, Division of Pediatric Surgery, Doernbecher
Childrens Hospital, Oregon Health and Science University, and Department of Pediatrics, Division of Pediatric Gastroenterology, Doernbecher Childrens
Hospital, Oregon Health and Science University, Portland, OR.

Address correspondence and reprint requests to Joel Friedlander, DO, M.Be, Digestive Health Institute, Anschutz Medical Campus, 13123 East 16th Avenue,
B290, Aurora, CO 80045 (e-mail: Joel.Friedlander@childrenscolorado.org).
The authors report no conflicts of interest.
Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated
photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are
to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

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1. Soylu AR, Buyukasik Y, Cetiner D, et al. Overt gastrointestinal bleeding in haematologic neoplasms. Dig Liver Dis 2005;37:91722.
2. Chen ZM, Shah R, Zuckerman GR, et al. Epstein-Barr virus gastritis: an underrecognized form of severe gastritis simulating gastric lymphoma. Am J Surg Pathol
2007;31:144651.
3. Hokama A, Taira K, Yamamoto Y, et al. Cytomegalovirus gastritis. World J Gastrointest Endosc 2010;2:37980.
4. Kalach N, Bontems P, Koletzko S, et al. Frequency and risk factors of gastric and duodenal ulcers or erosions in children: a prospective 1-month European multicenter study.
Eur J Gastroenterol Hepatol 2010;22:117481.
5. Nithiwathanapong C, Reungrongrat S, Ukarapol N. Prevalence and risk factors of stress-induced gastrointestinal bleeding in critically ill children. World J Gastroenterol:
WJG 2005;11:683942.
Copyright # 2012 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,
Hepatology, and Nutrition
DOI: 10.1097/MPG.0b013e318246deca

JPGN

Volume 55, Number 2, August 2012

119

Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.