Unexpected upper gastrointestinal bleeding in a well newborn: A case report

Abstract

Case Description: A one day old, 3.2 kg girl presented to a regional hospital with sudden onset massive haematemesis, melaena and haematochezia. She was delivered by spontaneous vaginal delivery at term with no antenatal or perinatal stressors identified and had been discharged home aged 14 hours. She was noted to be pale, tachycardic and had poor peripheral perfusion. She was resuscitated with crystalloid, fresh frozen plasma, and subsequently packed red cells as her haemoglobin was 82 g/l. Intravenous proton pump inhibitor (PPI) was started and she was retrieved to a tertiary paediatric centre. Emergency endoscopy showed erythematous friable mucosa at the duodenal bulb, duodenal cap ulcers and oedematous mucosa in the distal oesophagus. No haemostatic intervention was required. Biopsies confirmed duodenitis and oesophagitis. She remained stable with no further bleeding and was discharged 48 hours after endoscopy on high dose (3 mg/kg) oral PPI, aged 4 days. Review and repeat endoscopy is planned. Discussion and literature review: Massive upper gastrointestinal (GI) bleeding in neonates is uncommon. Reported causes include gastritis, oesophagitis, and ulcers, mainly gastric or oesophageal. Duodenal ulcers (DU) are uncommon with an incidence of 1.2% in bleeding neonates1. Metabolic acidosis, hypovolaemia, hypoxaemia, raised intracranial pressure and hypoglycaemia have all been reported to increase the risk of bleeding1. Additional risk factors including preterm birth, intensive care patients, coagulation disorders, sepsis, milk protein intolerance, and nasogastric tube trauma have been reported in neonates. Medications, particularly non-steroidal anti-inflammatory drugs, H. pylori infection, and Zollinger-Ellison syndrome are recognized in adults and older children. Management of GI bleeding in neonates is anecdotal, and previous reports have mainly used histamine antagonists. Unfortunately, 10% still had ulcers after one month of histamine antagonist treatment1. Other reported therapies in neonates include somatostatin analogues for variceal bleeding and surgery. Haemostatic treatments, such as sclerotherapy, thermocoagulation and clips have been used in adults and children but are problematic in the neonate due to lack of appropriate equipment and technical expertise. Additionally, neonates, due to their size, are considered high risk for complications such as perforation after haemostatic treatment. There is a single case report of heater probe coagulation in a neonate2. PPIs however, have been shown to be superior to histamine antagonists in healing bleeding ulcers3. Our case was successfully managed with high dose PPI only, although lower doses (1-2 mg/kg/day) have been used in conjunction with thermocoagulation in a neonate2. We report a case of a previously well newborn with no recognized risk factors with bleeding DU, who responded to medical management only. This case demonstrates the efficacy of high dose PPI in controlling bleeding DU in neonates.<br />