CLINICAL
NOTES
MASSIVE
BLEEDING
FROM
DUODENAL
ULCER
IN
INFANCY
TREATED
BY GASTRECTOMY
By J. R. Neilson, M.B.,* and J. H. Black, MB.
I
T IS tile 1)UPOSC of tiTus report to presenttile problems encountered in the
treat-ment of a child of 18 months of age who
suffered from severe gastro-intestinai
bleed-ing due to a duodenal ulcer. This record
with a 33-month follow-up can be added to
tile comparatively small list of surgical
pro-cedures to be found in the literature, as
treatment of massive hemorrhage from
pep-tic ulceration in infants and children.
CASE
REPORT
Baby girl, M.A.S., 18 months, Unit No.
26588, was admitted to hospital for observation
and for correction of dehydration after a 4-day
illness considered to be gastro-enteritis. The
OIlset of this illness had been characterized by
a high fever and vomiting without diarrhea.
Previous to admission a small amount of bright
red blood had been noticed in the vomitus on
OIlC occasion and also a single observation of
a similar amount of tar-like substance in the
stool. There was evidence to suspect that the
child also suffered from cramp-like abdominal
pain during this 4-day illness.
The patient was one of non-identical twins.
The birth weight was 6 lb. 6 oz. These were
the first-born children of healthy parents and
followed an uneventful pregnancy and delivery.
Both illfants had been particularly free of
illness, the home care had been excellent.
There was a history of a sudden
gastro-intestinal llaemorrhage in a paternal aunt at
9 years of age, which accompanied an attack
of chickenpox. The bleeding was not
particu-larlv severe and a complete survey excepting
From the Pediatric Division, Department of
Surgery, Vancouver General Hospital and the
Faculty of Medicine, University of British
Colum-bia, Vancouver, Canada.
(Subniitted for publication, May 5, 1954;
revi-sion accepted November 30, 1954.)
* ADDRESS: Medical-Dental Building, Vancouver 1,
B.C., Canada.
laparotomy failed to reveal a source. She has
not had a recurrence or any other evidence of
gastro-intestinal disturbance since then. The
family history is otherwise irrelevant.
On admission the infant was noted to be
drowsy, dry and flushed. The temperature was
normal and, with the exception of a reddened
throat, examination did not reveal other
ab-normality. Hemoglobin estimation was 14.2
gm. and the W.B.C. was 13,300. She was given
penicillin, suitable fluid therapy by
subcutane-ous route and allowed only water by mouth. On the third day after admission the patient
was obviously improved, but within an hour a
remarkable change occurred initiated by
marked apathy and pallor. She did not vomit
and she did not pass stool, the temperature
re-mained normal and there was no evidence of
pain. Abdominal examination revealed only the
suggestion of sausage-like masses, there was
no evidence of bleeding or mass on digital
cx-amination of the rectum. Hemoglobin
estima-tion at this time was 3.5 gm. Blood was
trans-fused into an ankle vein, a saline enema
pro-duced a large amount of tarry stool and a
barium enema outlined a normal colon.
Aspi-ration of the stomach disclosed a slight tinge of
red blood, insufficient to be of diagnostic aid.
Blood and electrolyte solutions were given
in adequate amounts with a gradual rise in
hemoglobin estimation but bleeding continued,
apparently in spells, each associated with
col-lapse of minor degree. After 48 hours of this
form of therapy and with the hemoglobin at
9.2 gm. a decision was made to explore the
abdomen in spite of the fact that a definite diagnosis had not been established.
At operation the colon and the lower third
of the small intestine were found to be filled with dark blood. There was patchy distribu-tion of blood in the middle third and none in
the proximal jejunum or duodenum or stomach.
NEILSON I)UODENAL ULCER IN INFANCY
II(.. I. Photograph of I)atHIIt (right) and tvin sister, tg :33k 2 \‘(L1 S iftcr p(r(it)11.
(l11Od(1lal cat) 1R)te(I and it s(CIlle(I to ie
(l()SelV adll(rellt to the prttl tract \Vilidh ‘as
1l5() tliCk(11((1 audi re(IdcIle(I. On further
cx-Phre sinai! aniount of i)ilc-stained Illucoid
siiljstance \VdS found above the 1)ylOrtls. Oii
closer ilIsp(CtiOIl this seenied to itve emerged
fmon a slit-like opening where the first portion
of the duodeiiiiui had l)e(O1l1e adherent to the
portal tract. It was felt that this opening could
have ieen produced b the traction illexposing
the area. Suction applied within the duodenum
through the opening b means of a small
catheter revealed only normal contents without
i)lOo(I. It was (leci(Ie(l to rej)air the opening,
011(1 to carm on with conservative therapy for
O suppOse(l mhiodeial ulcer. The hemoglobin
at conchisioti was 12.2 gm., blood
having bcei liberally administered.
Au excellent recovery followed and seemed
to justify the (IeciSiOll of conservatism, but on
the fourth post-operative day another bout of
I)leeding occurred with symptoms similar to
those illitiahly noted. The hemoglobin dropped
to 5.6 gm.
Blood replacenlent was again instituted ouxi
a 48-hour trail of topical tllronlhill and buffer
solution carried out, 0111% to be abandoned
vhiei l)lee(ling continued . Tile decision to
attack tile bleeding LM)int seenied niandatory
at this time, 6 days post-operative.
At tile second operation the duodenum was
u1)ened by a transverse postpyloric incision to
reveal a large ulcer on the posterior vall
cx-tending on to the superior surface of the first
1)OrtioIl of the duodenum. The previous repair \V05 intact. There ‘as no active i)leeding Oil
exiosure but a gentle wipe with a spoige
couse(I a frightening hemorrhage fronl a 1)Oillt
iii tile ceilter of the ulcer. This was easily
con-trolhe(1 l)y a suture ligature of fine silk.
After consideration of the lesion it
con-eluded tiiat gaStrectonly \VOS tile iIl(IiCatedI
metllod of treatlTlent. It vas (luite impossil)le
to dissect out the first I)ortioil of the duodenum;
consequently tile stuhll1) WS closed1 proximal
to the ulcer. Approximately two-thirds of the
stomach was resected and an ante-colic,
Polya-Hoffnieister type of gastro-jejunal anastoniosis
perfornlecl. Intranasal suction through a Levine
tube illtrOduced into tile afferent loop is
iii-stituted in order to protect the rather
made-(Iulte closure of duodenal StuIlli).
Tile hemoglobin on return to ward was 15.4
grn. and the 1)atient nla(Ie a erv satisfactory
recovery. Thlroughout the vhIoie course of
treat-IfleIlt a total of 3000 ii#{238}l.of whole 1)IoOd wa
given i)%’ transfusion.
The recovery from this illness and surgei y llaS beell surprisingl’ uneventful . For several
IlloIlti’1S tilere \vas sonic nausea after eating l)Ut
tiliS applied only to those occasions hien too
much food lac1 been taken and inure
l)(trticu-larlv to tile rate of ingestion. She was (lescribed
as being nervous for mnally ulonthis 011(1 at times
rem1uired Se(latiOll for restlessness ai RI inson)nia.
Hovever, there has been a gradual leturIl to
her anticipated normal behaviour patteril and
the parents regard her as entirely vell (Fig. 1).
Periodic checks have been made on the
Pr’-tient and her twin sister over a period of
3:3 months since operation in order to detect,
if possible, any interference with growth or
nutritioii. These children have beeui Oil
identi-cal diets. If tile patient is allowed a small
deficit for loss durillg the period of illness aild
compa-lge
Birth 6 veeks
1year
10 iiioiitlis
18 iiiontlts
3 years
.5 it). lo HZ. 6 lb. 6oz.
14 lb. 0 HZ. 13 lb. i oz.
0 lb. 6 oz. 19 lb. 14 oz.
Ii). 0 oz. 20 lb. 8 oz.
Operation
34 lb. 0 HZ. 311b. 0 OZ.
(33 iuios. post-p)
RBC- 4.29M RBC- 4.86M
lIb. -11 .9 gnu. JIb. -12.7 gm.
CLINICAL NOTES 435
rable rate of growth has been maintained
(Table I).
The effect of gastrectomy at this age, on the
l)atiellts ability to maintain a normal blood
l)llaIlce constituted a problem, the outcome
of which as anxiously awaited. Blood studies
ill gastrectomized adults have silO\VIl a rattler
Wi(le range of results but not a definite pattern.
\Ve were unable to find a record of a similar
survey ii) children of any age. At the 2-year
pstper1tive periodi our l)ltie11t demonstrated
a (leflilite anenlia of the hypochromic variety
(Table I). Small amounts of iron (ferrous
suil-1)hate) were givea and continued for 3 months
at vhich tulle it ‘as discontinued by the parent
l)ecause the child was SO obviously well. The
last 1)100(1 examination was done at the
con-elusion of a 6 months’ absence of medication
aild is reported by our hematologist to be
entirely normal 01 all respects.
Iloentgenographic exaniination at the 2-year
post-operative period silows satisfactory
func-tiOiliilg of tile remailliilg portion of iler stomach
without evidence of organic derangement or
complication (Fig. 2).
REVIEW OF LITERATURE
In 1941 Bird, Limper and Mayer1 in an
excellent survey of the available literature
repOrtedi 119 surgical procedures for the
relief of peptic ulceration and its
complica-tiOlls in infants and children. One
gastrec-tom’ was recorded by Stohr’ in the
2-year-T.BLE I
WEIGHT (‘ui.knT
Twin #2
Twin #1 (patient)
(4 uiios. post- I{BC- 4. 3 M RBC- 4. 15 M
up) Jib. -1i.3 gun. Jib. -10.2 guI.
years 36 lb. 0 os. 34 lb. 0 oz.
Fic. 2. Roentgenogranl at :3h ears, 2 years
P0St-l)(r1ti\e.
and-under age group but survival
did
notfollow. McAleese and Sieber continued the
review and in 1952 were able to acid a
further list of 1 15 cases of peptic ulcer from
the available literature. Twenty-nine pa-tients 111 this series had been subjected to
surgery with 1 gastrectomy of Bilroth Type
1 by Karistrom,& age not mentioned but
survival followed. Hollander and Stark1
re-ported a post-pyloroinyotomy duodenal
ulcer with severe bleeding but the patient
succumbed before surgical condition could be attained. Plummer and Stabins were
able to report success in 2 infants in which
the bleeding originated in anterior and
accessible duodenal ulcers, by local excision
without anastomosis.
Perforation of ulcers in tile newborn has
been found and treated on several
occa-sions. Our records show only one such
patient whose lesion was discovered at
autopsy.
DISCUSSION
Tile overall problem of PePtic ulceration
has been well and adequately covered
436 NEILSON DUODENAL ULCER IN INFANCY
to the general conclusions made by these authors, but the opinions already expressed
should be emphasized: This condition in
tile infants is most frequently associated
with other illness of some sort and even-tually is discovered by its complications,
particularly those of perforation,
hemor-rhage or stenosis. The age group of 2-to-6
years is singularly exempt from peptic
ulcer-ation while older children follow the
symp-torn pattern seen in adult life.
In consideration of the one complication in the younger age group, bleeding, one is
impressed by the consistent finding that the
majority of duodenal ulcers are located on
the posterior wall. This complicates the
sur-gical approach to correction especially as
warning has been issued by authorities in pediatric surgery1#{176} that a conservative atti-tude should be maintained in this age group
particularly.
An infant with severe bleeding from the gastro-intestinal tract merits urgent
consid-eration. Such an infant withstands blood
loss poorly and may frequently not respond
to replacement therapy. When should the
more aggressive form of therapy be
under-taken? A 24-hour limit of conservative meas-ures has been set’ but many factors alter this decision, such as, available surgical and
anesthetic facilities, including personnel.
Perhaps a joint decision on type of treat-ment should be made by a group
repre-senting all the possible therapeutic agencies
in the same fashion as has been found so
satisfactory in care of adults with similar conditions. These clinical conferences must
of necessity be held at frequent intervals. It
must also be mentioned that even very ill infants withstand surgery remarkably well if such is undertaken prior to the point of
physical and metabolic exhaustion.
It would appear that many infants with
bleeding from peptic ulceration do not
vomit or have blood in the stomach on
aspiration. Examination by barium meal in
this acute stage, such as may be of
assist-ance in the adult, has not been reported so its application here is not only of doubtful
value but might even be hazardous.
Conse-quently the final diagnosis must be made at
laparotomy and by exclusion of other
possi-ble sources of bleeding. The time factor is
of importance due to heat loss and other
disturbances during surgery, thus, it might
be argued that direct inspection of the posterior wall of the duodenum by incision
is advisable. It would have been so in our patient at the first operation.
With the active bleeding under control and with the offending lesion under com-plete survey it became necessary in this patient to pause and carefully consider what
further corrective measure should be
under-taken. The continuity of the gastro-intestinal
tract had to be restored to include if
possi-ble a by-pass of the extensive ulceration. The local condition about the first and see-ond portions of the duodenum very defi-nitely precluded its use in any of the various
pyloroplastic or anastomotic procedures which are available in adult surgery under
similar
circumstances. Gastrojejunostomyalone in the younger age group has a high
incidence of marginal or stoma! ulceration; it is not a recommended surgical treatment
of duodenal ulcer. The decision to perform
a moderately extensive resection with gas-trojejunal anastomosis was made with
reluc-tance but under the circumstances it seemed
to be entirely justified from a restorative
point of view. The antecolic anastomosis
was chosen as this type would facilitate the
performance of some reconstructive
proce-dure if such became necessary in the future.
It is a recognized and admitted fact that
gastrectomy in a young child should always
be avoided if at all possible. In this
par-ticular instance the hazard had to be ac-cepted as a calculated risk which until the
present at least seems to be minimal. It
would
be
ridiculous to draw conclusionsfrom a single experience, also the long-term
result might be just as disappointing as it
com-CLINICAL NOTES 437
pensatory abilities of the very young
sur-gical patient.
SUMMARY
1. An infant of 18 months with massive
bleeding from a duodenal ulceration has
been treated by gastrectomy after failure of
conservative medical and surgical methods
of treatment.
2. A 33-month follow-up shows excellent
progress.
3. It is hoped that future reports, espe-cially of follow-up surveys, will aid us in the choice of a method of treatment in those
patients where radical care seems indicated.
ACKNOWLEDGMENTS
Grateful appreciation is expressed to Dr.
J.
W. Whitelaw and Dr. H. RockeRobert-son for their valuable advice and help with
this patient.
REFERENCES
1. Bird, C. E., Limper, M. A., and Mayer,
J.
M.: Surgery in peptic ulceration ofstomach and duodenum in infants and children. Ann. Surg., 114:526, 1941.
2. Stohr, R. : Uber einen Fall von Ulcus am
Pylorus bei cinem 22 Monate alten Kinde ais Folge einer
LOtwasserver-giftung. Zentralbi. Chir., 52 (2) 2644,
1925.
3. McAleese,
J. J.,
and Sieber, W. K. : Thesurgical problem presented by peptic
ulcer of the stomach and duodenum in
infancy and childhood. Ann. Surg., 137: 334, 1953.
4. Karlstrom, F. : Ulcus-Krankheiten beim
Kinde mit besonderer Beruck-sichtigung der Haufigkeit. Helvet. paediat. acta, 4:
455, 1949.
5. Hollander, M. H., and Stark, M. W.: Duodenal ulcer in infancy. PEDIATRICS, 6:676, 1950.
6. Plummer, C. W., and Stabins, S.
J.
:Bleed-ing duodenal ulcer in infancy-Surgical
problem.
J.
Pediat., 37:899, 1950.7. Wright, L. T., and Scott, B. E.: Perforated gastric ulcer in a newborn infant.
J.
Pediat., 37:905, 1950.
8. Donovan, E.
J.,
and Santulli, T. V.: Peptic ulcer in infants and children. Am.J.
Dis. Child., 69:176, 1945.
9. Moncrieff, W. H., Jr.: Perforated peptic
ulcer in the newborn-Report of a case
with massive bleeding. Ann. Surg., 139: 99, 1954.
