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| CASE REPORT |
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| Year : 2023 | Volume
: 10
| Issue : 3 | Page : 118-120 |
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Massive upper gastrointestinal bleed masquerading as portal hypertension due to foreign body ingestion in an infant: A case report
Shaifalika Thakur, Sunil Kishore, Rakesh Kumar
Department of Paediatrics, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| Date of Submission | 15-Mar-2023 |
| Date of Decision | 19-Apr-2023 |
| Date of Acceptance | 23-Apr-2023 |
| Date of Web Publication | 19-May-2023 |
Correspondence Address:
Dr. Sunil Kishore
201, Ward Block, Department of Paediatrics, Indira Gandhi Institute of Medical, Sciences, Patna - 801 503, Bihar
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jpcc.jpcc_16_23
Massive gastrointestinal (GI) bleed frequently presents as a pediatric emergency, which needs to be aggressively managed and thoroughly investigated. We report the case of a 9-month-old infant who presented with a massive GI bleed due to foreign body ingestion. The chest X-ray showed a hairpin lodgment in the stomach. The patient had recurrent GI bleeds leading to shock. Once stabilized, a hairpin was retrieved from his gastric rugae folds by upper GI endoscopy. Our case highlights the need of looking beyond the routine causes in cases of intractable GI bleed, especially in the pediatric age group.
Keywords: Acute upper gastrointestinal bleed, foreign body ingestion, variceal bleed
How to cite this article:
Thakur S, Kishore S, Kumar R. Massive upper gastrointestinal bleed masquerading as portal hypertension due to foreign body ingestion in an infant: A case report. J Pediatr Crit Care 2023;10:118-20 |
How to cite this URL:
Thakur S, Kishore S, Kumar R. Massive upper gastrointestinal bleed masquerading as portal hypertension due to foreign body ingestion in an infant: A case report. J Pediatr Crit Care [serial online] 2023 [cited 2023 Jun 2];10:118-20. Available from: http://www.jpcc.org.in/text.asp?2023/10/3/118/377432 |
| Introduction | |  |
Massive gastrointestinal (GI) bleed and subsequent hypovolemic shock are often encountered in an intensive care unit. In the pediatric age group, the usual culprits of upper GI bleed vary with age and geography. In the Indian setting, variceal bleeding predominates the list of causes, while in Western countries, bleeds are more frequently attributed to ulcers, gastritis, esophagitis, and so on.[1] While foreign body ingestion is common in infants, most of them make a shy passage out of the alimentary canal. Occasionally, these can also be a cause of secondary GI bleeding.[2] However, these have rarely been reported to cause massive upper GI bleeds leading to circulatory collapse. In such cases, combative management of shock and intervention to retrieve the foreign body is necessary.
Hence, it is necessary to assume a possibility of foreign body ingestion, even if history suggests another diagnosis.
| Case Report | | |
A 9-month-old male child came to the emergency room with a history of two episodes of hematemesis along with a complaint of the passage of black tarry stools on multiple occasions in the past 5 days. The onset of symptoms was sudden and associated with progressive paleness of the body. Low-grade fever was also documented after 2 days of onset of symptoms which subsided on antipyretic medication. No history of spontaneous or prolonged bleeding, blood in urine, easy disability, jaundice, or edema was present. The mother gave no recollection of ingestion of any foreign body during history taking. The child had two units of packed blood cells transfusion before he was brought to our center. A thorough examination revealed normotensive patient with severe pallor and tachycardia on admission, signaling toward compensated shock. The systemic examination was unremarkable.
Blood investigations revealed severe anemia with hemoglobin 3.5 g/dl, elevated C-reactive protein of 40 mg/dl, an elevated corrected reticulocyte count of 7%, and a positive report of occult blood in the stool. The liver function test and kidney function test were normal, international normalized ratio was 1.2, and the chest abdominal radiograph revealed the presence of a U-shaped metallic pin with an estimated 7–8 cm arm, lodged in the stomach [Figure 1]. | Figure 1: X-ray chest including abdomen showing U-shaped metallic pin lodged in stomach
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Since the foreign body had already caused significant blood loss, the need for an urgent endoscopic retrieval of the pin was planned. However, the patient suffered another episode of massive upper GI bleed along with melena, progressed to decompensated shock and hence required immediate resuscitation.
After multiple transfusions in accordance to massive transfusion protocol, and hemodynamic stabilization of the patient, an upper GI endoscopy was performed and the hairpin was recovered. The hairpin was lodged in the gastroesophageal junction, while the base of the pin, along with an attached pearl motif, was present in the cardiac region of the stomach. The stem was first pushed into the stomach and then retrieved, spherical part first, with the aid of Roth net.
The endoscopy also revealed multiple ulcerations and erosions in the lower esophagus along with clots, signifying the sources of recent bleeds [Figure 2]. | Figure 2: Endoscopy also revealed multiple ulcerations and erosions in the lower esophagus along with metallic hair pin. White arrow shows the base of hair pin. Metallic pin with bead motif at base
Click here to view |
The pathological examination suggested a metallic U-shaped hairpin, with a pearl spherical ball attached to the base of the pin. Each arm measured 8 cm. The paint on the pin was eroded signaling that the ingestion could have been a silent remote event that caused repeated trauma to the mucosa of the stomach and esophagus.
The hemoglobin of the patient was normalized by multiple transfusions and the risk of rebleeding was attempted to be minimized with various medical approaches. Pediatric surgical and cardiothoracic vascular surgery teams were involved to address the repercussions of foreign body ingestion, and a second attempt at endoscopic management followed by exploratory surgery to address the multiple bleeders was decided. However, the patient continued having multiple consecutive episodes of upper GI bleeding postoperatively, and despite the most aggressive management, could not survive massive ongoing blood loss. The patient died of refractory hypovolemic shock due to massive upper GI bleeding, likely due to torrential bleed of a major vessel from the eroded mucosal bed.
| Discussion | | |
Ingested foreign bodies are a commonly encountered problem in a pediatric emergency department, more so in the case of toddlers.[3] The usually ingested objects are those which are easily grasped and mouthed by children. These frequently include coins, nuts, toys, and small ornaments. Ingestion of larger objects is uncommon due to the sheer difficulty that the child faces while trying to grip such objects.[4] Usually, such a child presents to the emergency with the main complaint of a history of ingestion of a foreign body, with or without accompanying symptoms. When symptomatic, the complaints can include drooling, excessive salivation, vomiting, refusal to feed, pain in the abdomen, chest pain, hematemesis, and melena. In cases of the relatively past events of ingestion, the child may present with weight loss, fever, and failure to thrive.[5] The diagnostic challenge arises when a child presents with a multitude of vague symptoms, with no recollection of an event of foreign body ingestion before the onset. Thus, it is obligatory as pediatricians to keep the possibility of foreign body ingestion at a high index of suspicion when dealing with a rather healthy child with indeterminate symptoms.
In the cases where the only complaint is significant history and the child otherwise appears asymptomatic, it is imperative to stay watchful to know the progression of the foreign body through the GI passage with the help of serial X-rays and thorough monitoring for the development of any new symptoms. In the other cases where symptoms of respiratory distress of GI tract obstruction, hemorrhage, or perforation have appeared, or the ingested object is that of concern, like a battery, early and urgent intervention in the form of endoscopic retrieval is the mainstay of treatment.[6],[7]
Rarely do foreign bodies cause massive upper GI bleeding in adults, but in children, it is responsible in a fair number of cases.[8] While we rely solely on the informant's recollection of the events leading to the hospital admission, the history of ingestion may frequently be missed. It is also seen that the period between the ingestion and the symptoms is variable, from days and weeks up to months. In such cases, it becomes more difficult to elicit a positive history from a caretaker. Therefore, in patients who have symptoms like upper GI bleed without any suggestive history or investigation, the possibility of foreign body ingestion should always be on the differential. The symptoms that this foreign body would cause, depend on its shape and size, as well as the location where the foreign body gets stuck. A narrow passage increases the risk of trauma, as was evident in this case.
Bleeding is a leading complication of foreign bodies in the GI tract, along with other complications like ulceration, perforation, abscess formation, and infection.[9] The bleeding could be due to the involvement of a major vessel, an aberrant vessel, or erosion of the vascular ulcer bed. Bleeding should be managed aggressively whether before, after, or during the endoscopic retrieval of the foreign body. Immediate and meticulous resuscitation is the key to combating the ongoing losses while addressing the main cause of the disease.[10]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's legal guardian has given the consent for images and other clinical information to be reported in the journal. The patient's legal guardian understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
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