Balloon Embolization of a Bleeding Gastroduodenal Artery in a 1-Year-Old Child

(1)

Balloon

Embolization

of a Bleeding

Gastroduodenal

Artery

in a 1-Year-Old

Child

Joseph

S Janik,

MD, J. A. Gordon

Culham,

MD,

Robert

M. Filler,

MD,

Barry

Shandling,

MB,

and

Gustavo

Stringel,

MD

From the Departments of Radiology and General Surgery, The Hospital for Sick Children, Toronto

ABSTRACT. Severe stress can produce ulceration and uncontrollable hemorrhage in the pediatric age group. Modern angiographic techniques, using embolization of a

Silastic balloon to occlude a visualized bleeding vessel,

can successfully control hemorrhage and avoid surgical

intervention and its resultant disordered gastric physiol-ogy. Recently this technique was used to control

hemor-rhage from the gastroduodenal artery in a 1-year-old child

with severe respiratory sepsis. This is the youngest re-ported child in whom the technique has been used to control bleeding from this vessel. Pediatrics 7:671-674,

1981; angiographic balloon embolization, gastroduode-nal hemorrhage.

Severe upper gastrointestinal hemorrhage from diffuse hemorrhagic gastritis or a specific bleeding ulcer site is an uncommon entity in children. Bleed-ing in children is usually not indicative of an under-lying ulcer diathesis.”2 In the past, surgical inter-vntion was the only alternative when medical

man-agement failed. Each surgical procedure has the potential for disordered gastrointestinal

physiol-ogy.’ In recent years, however, advances in

angio-graphic technique and facilities at adult centers have allowed localization of bleeding site and con-trol of hemorrhage in a variety of circumstances,8’4 and such techniques are now being applied to the child.6”52’

CASE REPORT

A previously healthy, 10-kg 1-year-old boy, with a history of pica, was admitted to a nearby hospital for

Received for publication June 2, 1980; accepted Aug 8, 1980. Reprint requests to (R.M.F.) Department of Surgery, The Hos-pital for Sick Children, 555 University Aye, Toronto, Ontario

M5G 1X8, Canada.

stridor and upper respiratory tract infection. He failed to respond to conservative management. Bronchoscopy re-vealed subglottic narrowing one week later. Respiratory

arrest immediately followed bronchoscopy, and

emer-gency tracheotomy was performed. Respiratory difficulty

persisted, and bilateral pneumothoraxes, seen on chest

x-ray, were stabilized with the bilateral insertion of

19-gauge Teflon intravenous cannulas.

The boy was transferred to The Hospital for Sick Children (HSC), Toronto. Bilateral chest tubes were

in-serted to stabilize the pleural spaces. Bronchoscopy was

repeated, and subglottic stenosis was confirmed.

Subse-quently the child required ventilatory assistance for 18 days, pleural drainage for pneumothorax, effusion, and

empyema for 24 days, and antibiotic and antipyretic therapy for 28 days. Despite antacid and H2-receptor

antagonist therapy, gastrointestinal hemorrhage occurred on the 4th, 7th, 10th, and 13th days after transfer to HSC.

In each instance the blood pressure fell to 70 to 80 mm Hg, pulse rose to 180 to 200 beats per minute, and hemoglobin level ranged from 7 to 8 gm/i#{174} ml. He required between 250 to 750 ml of blood at each episode. Results of coagulation studies were normal. Between bleeding episodes hemoglobin level ranged from 1 1 to 12

gm/lOO ml.

On the 12th day upper gastrointestinal tract contrast

studies revealed no abnormality. On the 14th day endos-copy demonstrated a “clot” in the first portion of the duodenum. There was no bleeding encountered and the

clot was left undisturbed.

On the 16th day hemorrhage recurred. Blood was recovered from the tracheostomy tube as well as from the nasogastnc tube. Inasmuch as no definite gastrointestinal

site of bleeding had been identified and as there was a

possibility that bleeding was from an aberrant vessel near the tracheostomy tube, the child was taken to the an-giography suite after stabilization with 1,500 ml of blood.

(2)

, I

:r)

7 A

B

duodenal artery (arrowhead) and extravasated contrast material (asterisk) in pylorus and duodenum.

672 BALLOON

EMBOLIZATION

and common hepatic artery into the proximal

gastroduo-denal artery. An angiogram at this site showed an aneu-rysm of the gastroduodenal artery and massive

extrava-sation into the duodenum (Fig 1).

The child’s condition remained stable and as control of

further bleeding could be achieved if necessary by infu-sion of vasoconstrictor drugs, it was decided to attempt embolization of the bleeding site. Gelfoam (The Upjohn Co) particles were inserted through the catheter and

occlusion of the right gastroepiploic artery beyond the

aneurysm was accomplished. Thrombus propagated prox-imally into the aneurysm but did not occlude the bleeding

site. An inflatable-detachable Silastic balloon (Mini-Ba!-loon, Becton-Dickinson, Rutherford, NJ, Fig 2) was

there-fore inserted into the gastroduodenal artery proximal to

the aneurysm. It was inflated with contrast medium, and

its position was confirmed angiographically. Then the balloon was detached (Fig 3). The short distance between

the aneurysm and the origin of the gastroduodenal artery resulted in the balloon protruding into the proper hepatic

artery. Because proximal hepatic artery occlusion is well

tolerated22 and collateral flow was evident angiographi-cally, this position was accepted.

No further gastrointestinal hemorrhage occurred. Bowel function was not disturbed as illustrated by a film of the abdomen 20 hours after angiography on which the

balloon is seen in place and the bowel has almost

corn-pletely emptied itself of the blood and extravasated

con-trast medium (Fig 4). Oral alimentation was started within 48 hours of balloon embolization. Two weeks later

liver scan and liver function tests were performed;

find-ings were normal. Pulmonary sepsis resolved and the

tracheostomy tube was removed. Follow-up one year later

showed a healthy 2-year-old who weighed 12.8 kg. He was eating a normal diet and had no gastrointestinal

complaints.

DISCUSSION

In the last 15 years advances in angiography have

allowed the localization8 and the control9’4 of gas-trointestinal bleeding in adults with reasonable

suc-cess and minimal morbidity. In a smaller number

ofreports in children angiographic embolization has been used to control hemoptysis in children with

cystic fibrosis,’5 hematemesis from an esophageal

ulcer,’6 and traumatic hepatic, splenic, and renal hemorrhage.’72#{176} This limited experience in children is due, in part, to the infrequency of major hemor-rhage in children, the lack of appropriate catheter

systems, and a reluctance on the part of many angiographers to perform such a technique in the small child. However, the alternative is gastrointes-tinal surgery and its potential for a lifetime of disordered gastric physiology.’7

The surgical procedures available for controlling hemorrhage from acute stress or peptic ulcers are

numerous.’5 In general, a single bleeding stress ulcer is best treated by direct suture ligation. Vagal denervation is unnecessary. Stress hemorrhage from a Cushing stress ulcer requires vagal dener-vation, pyloroplasty, and suture ligation because

Fig 1. Selective gastroduodenal arteriogram in early (A) and late (B) arterial phases showing aneurysm of

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(3)

i4

central nervous system disease alters gastric acid physiology. Moderate resective surgery with vagot-omy has been recommended for hemorrhage

see-ondary to peptic ulcer disease.25 All of these

pro-cedures carry the risk of malnutrition, dumping,

bile reflux gastritis, and anemia.7 Children who

have had gastric resections ranging from 30% to

75% have shown normal growth, some retardation

in weight gain, and frequent iron deficiency

ane-mia.’ Children with the Zollinger-Ellison syn-drome and therapeutic total gastrectomy have faired better, but iron and vitamin B,2 deficiencies

are commonplace.2’

The development of an inflatable-detachable

Si-Fig 2. Mini-Balloon: syringe injection chamber, 2-F

catheter, and 1-mm inflatable-detachable balloon

de-flated (arrow).

Fig 3. Mini-Balloon (arrowheads) inflated and

de-tached in gastroduodenal artery and extending into

com-mon hepatic artery.

Fig 4. Plain film of abdomen 20 hours after placement

of Mini-Balloon. Balloon is in place (arrowhead) and extravasated contrast material (formerly in duodenum)

has passed into distal colon.

lastic balloon of a size appropriate for use in chil-dren has allowed small children to benefit from angiographic intervention. Furthermore, the bal-loon device, which can be inflated, have its positions checked and repositioned, or in fact be readily

removed, is a much safer technique than other devices or particles.’2’4 This approach can be used to control not only bleeding but also shunting through arteriovenous malformations of fistulas,

and tumor vascularity preoperatively.

Because two or more hours may be necessary to prepare for angiography and to localize the bleeding

site, this approach cannot be considered in

situa-tions in which blood transfusion cannot keep up

with losses. In addition, as emergency angiography and embolization in the small child are challenges to the skill of the expert, they should not be

at-tempted by the novice. The angiography suite must

be suitably equipped to permit anesthesia backup and to provide for the sudden need for resuscitation. Finally a full array of catheterization equipment

must be available. This technique is applicable to any child with gastrointestinal hemorrhage as long as the above criteria for safe angiography are met. Its greatest benefit might be realized in children who might tolerate surgery poorly, such as those

(4)

674 BALLOON

EMBOLIZATION

REFERENCES

1. Curci MR, Little K, Sieber WK, et a!: Peptic ulcer disease in

childhood re-examined. J Pediatr Surg 11:329, 1976 2. Seagram CG, Stephens CA, Cumming WA: Peptic ulceration

at The Hospital for Sick Children, Toronto, during the 20

year period, 1949-1969. J Pediatr Surg 8:407, 1973

3. Moore TC: Gastrectomy in infancy and childhood. II.

Re-sults of an international survey. Ann Surg 162:91, 1965

4. Johnston PW, Snyder WH: Survey of vagotomy and

pylo-roplasty in infants and children. Am J Surg 120:173, 1970 5. Tsuchida Y, Makino S, Ishida M: A follow up study of

subtotal gastrectomy in infancy and early childhood. J

Pe-diatr Surg 9:499, 1974

6. Filston HC, Jackson DC, Johnsrude IS: Arteriographic em-bolization for control of recurrent severe gastric hemorrhage

in a 10 yr old boy. J Pediatr Surg 14:276, 1979

7. Roberts JW, Hardin WJ: Postoperative bile gastritis. Surg Clin North Am 59:781, 1979

8. Nusbaum M, Baum S: Radiographic demonstration of

un-known sites of gastrointestinal bleeding. Surg Forum 14:374, 1963

9. Baum S, Nusbaum M: The control of gastrointestinal hem-orrhage by selective mesenteric arterial infusion of vasopres-sion. Radiology 98:497, 1971

10. Rosch J, Dotter CT, Rose RW: Selective arterial infusions

of vasoconstrictors in acute gastrointestinal bleeding. Ra-diology 99:27, 1971

1 1. Roach J, Dotter CT, Brown MJ: Selective arterial

emboli-zation: A new method for control of acute gastrointestinal

bleeding. Radiology 102:303, 1972

12. White RI, Jr, Ursic TA, Kaufman SL, et al: Therapeutic

embolization with detachable balloons: Physical factors in-fluencing permanent occlusion. Radiology 126:521, 1978 13. White RI, Jr, Kaufman SL, Barth KH, et al: Embolotherapy

with detachable silicone balloons: Technique and clinical

results. Radiology 131:619, 1979

14. White RI Jr, Kaufman SL, Klemens HB, et al: Therapeutic embolization with detachable silicone balloons: Early clinical experience. JAMA 241:1257, 1979

15. Schuster SR, Fellows KE: Management of major hemoptysis in patients with cystic fibrosis. J Pediatr Surg 12:889, 1977 16. Michal JA, Brody WR, Walter J, et a!: Transcatheter

em-bolization of an esophageal artery for treatment of a bleeding esophageal ulcer. Radiology 134:246, 1980

17. Goldblatt M, Goldin AR, Shaff MI: Percutaneous

emboliza-tion for the management of hepatic artery aneurysms. Gas-troenterology 73:1142, 1977

18. Eggink WF, Periberger RR, VanUrk H: Angiographic control of traumatic hemobiia by selective arterial embolization. Br JSurg64:635, 1977

19. Katzen BT, Rossi P, Passariello R, et al: Transcatheters

therapeutic arterial embolization. Radiology 120:523, 1976 20. Reuter SR, Chuang VP: Control of abdominal bleeding with

autogenous embolized material. Radiologe 14:86, 1974 21. Granmayeh M, Wallace S, Schwarten D: Transcatheter

oc-clusion of the gastroduodenal artery. Radiology 131:59, 1979 22. Petterson H: Arterial collaterals in intrahepatic arterial

oc-clusion. Acta Radiol 16:401, 1975

23. Wilson SD, Ellison EH: Total gastric resection in children

with the Zollinger-Ellison syndrome. Arch Surg 91:165, 1965

(5)

1981;67;671

Pediatrics

Stringel

Joseph S. Janik, J. A. Gordon Culham, Robert M. Filler, Barry Shandling and Gustavo