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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 68-70

Use of variceal banding in gastric polyps bleed-A prototype technique in children


1 Department of Paediatric Gastroenterology, Apollo Childrens Hospital, Chennai, Tamil Nadu, India
2 Department of Paediatric Surgery, Apollo Childrens Hospital, Chennai, Tamil Nadu, India, Indiaz

Date of Submission12-Dec-2021
Date of Decision02-Feb-2022
Date of Acceptance02-Feb-2022
Date of Web Publication23-Mar-2022

Correspondence Address:
Dhanasekhar Kesavelu
Consultant Pediatrician and Paediatric Gastroenterologist, Flat No. HIG 1052-B, Opp. To The Banyan, Mogappair Eri Scheme, Chennai - 600 037, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_47_21

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  Abstract 


An 8-year-old girl with a known history of Peutz‒Jeghers syndrome presents a history of hematemesis to the emergency room following an episode of reaching in the early hours of the morning. Her initial evaluation showed a hemodynamically stable child but had multiple episodes of retching which were managed conservatively. She has had a past history of acute pancreatitis for which she was in pancreatic supplements and she also had a magnetic resonance imaging of the brain which was normal. She presented with a history of ileo-ileal intussusception for which she was operated 5 years ago with an end-to-end anastomosis and she has been asymptomatic since. Her annual endoscopic surveillance showed polyposis of the colon which was resected and she was under constant follow-up. She had an episode of hematemesis was an acute episode which needed evaluation with an upper gastrointestinal (GI) endoscopy which showed the presence of polyps in the gastric antrum and pylorus with Grade 2 esophageal varices. She underwent prophylactic variceal banding for her esophageal varices. Further upper GI endoscopy evaluation showed the presence of polyps in the gastric antrum, body, and pylorus. We decided to use the variceal bands to ligate the gastric polyps as an unorthodox conventional technique, as the risk of bleeding and perforation are high in polypectomy. We Find banding of gastric polyps a very safe and effective method to remove gastric polyps in the stomach.

Keywords: Banding, child, Peutz‒Jegher, polyp, prototype


How to cite this article:
Kesavelu D, Satheesan R. Use of variceal banding in gastric polyps bleed-A prototype technique in children. Gastroenterol Hepatol Endosc Pract 2022;2:68-70

How to cite this URL:
Kesavelu D, Satheesan R. Use of variceal banding in gastric polyps bleed-A prototype technique in children. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 May 23];2:68-70. Available from: http://www.ghepjournal.com/text.asp?2022/2/2/68/340394




  Introduction Top


Prospective studies indicate the risk of bleeding between 6% and 7.2% as a common complication in patients who undergo electrocautery snare polypectomy for upper gastrointestinal (GI) polyps.[1],[2],[3] Adrenaline injection at the base of the polyp and placement of a metallic clip has been used in the prophylaxis of preventing bleeding prepolyp removal. Detachable snares have been used in removing polyps with good success rates[4] and minimal bleeding.

Previous study results implied that a strangulating technique alone could achieve the bloodless transaction of GI neoplasm.


  Case Report Top


Our patient is an 8-year-old child who is known case of Peutz‒Jeugher syndrome who presented with a history of acute upper GI bleeding following an episode of retching. Parents reported a significant amount of hematemesis (approximately 100 ml). On initial evaluation, the child was hemodynamically stable and her laboratory parameters were within normal limits. We decided to proceed to evaluate the cause of her upper GI bleeding with an endoscopy.

Under general anesthesia, her upper GI tract showed multiple polyps in the body, antrum, and pylorus. The largest active bleeding polyps were found at the body of the stomach which was banded.

Immediate arrest of bleeding was proposed using (esophageal band ligation [EBL]) as it was considered by both the clinicians as the most rapid and easy to access treatment with minimal risk when compared to conventional polypectomy.

EBL was carried out with a GIF 0150 endoscope (Olympus Optical Co., Ltd., Tokyo, Japan) and a 19 cm flexible over the tube. A transparent hood was set at the end of a scope that was equipped with a pneumo-activated esophageal variceal ligation (EVL) device set (Cook Medical Inc. MBL06). The device is set with two tubes: air feeding tube, sliding tube and a shooter device which would shoot the rubber band which is operated by the endoscopist.

The child underwent general anesthesia and the procedure was carried out with airway protection. The patient was kept nil by mouth for 6 h and clear fluids were commenced after this period of observation. The child tolerated this procedure well was discharged the following day.

She was brought back for repeat endoscopy to assess the lesions in 2 weeks. The repeat endoscopy showed full resolution of symptoms and a complete disappearance of the polyp. Complications, such as bleeding or perforation, were not noted at the site of EBL. The ulcer base was seen corresponding to the site of banding.


  Discussion Top


Peutz-Jeghers syndrome (PJS) is an inherited polyposis syndrome in which multiple characteristic polyps occur in the GI tract, associated with mucocutaneous pigmentation, especially of the vermilion border of the lips. It is inherited in an autosomal dominant manner and is caused by a germline mutation in the STK11 (LKB1) gene. The incidence of this condition is estimated to be up to 1 in 200,000 live birth.[1],[5],[6]

Polyps in PJS carry a high risk of intussusception and it is necessary to remove it to minimize the intussusception. Since PJ polyps do not become malignant in childhood and they do not necessarily need polypectomy to reduce cancer risk.[7]

The size of the polyp which needs to be removed remains an area of debate and discussion.

Our prototype case report shows that the use of esophageal banding for hyperplastic polyps in the stomach leads to avascular necrosis without any complications. To our knowledge, this is the first pediatric case report to show that the use of EBL‒which has been used in elective cases may also be used for emergency management of bleeding polyps.

The multiple modalities of managing a GI polyp are

  • Endoscopy
  • Laparoscopy
  • Laparotomy.


Hyperplastic polyps in the stomach are usually asymptomatic, endoscopic polypectomy data in pediatric population remains extremely sparse. The St Marks case series (which is a mix of adult and pediatric cases) shows that the risk of perforation is very high in polyps above the size of 2 cm. There is no data to suggest on what size polyps need resection but it is considered safe not to resect polyps that are between 3 and 5 mm in size. While larger polyps will need an endoscopic polypectomy or a safe elective wedge laparoscopic resection.[8]

The major aims of doing a polypectomy are preventing intussusception and saving the bowel and preventing GI bleeding.[9] The current recommendations suggest removing polyps of 1.5 cm to 2 cm in size and to remove polyps under the size of 1.5 cm if they cause symptoms,[9] for example, in smaller children under 25 kg even smaller polyps may also cause symptoms.[10]

The current ESPGHAN guidelines recommend upper GI endoscopy, colonoscopy, and (video capsule endoscopy) should commence no later than 8 years in an asymptomatic individual with PJS, and earlier if symptomatic.[11],[12]

The common surveillance should be carried out once in 3 years after explaining and obtaining consent for the procedure.[13],[14]

General consensus is to do elective polypectomy in patients to prevent polyp-related complications. The most anticipated complication of the PJS polyps is intussusception. Elective removal of >1.5–2 cm polyps are advised to prevent intussusception. Endoscopic, surgical, and/or combined approach have their merits and demerits. The choice of modality should be made on an individual basis, depending on the site and size of the polyp, and the endoscopic expertise available locally.[15]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names 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.



 
  References Top

1.
Online Mendelian Inheritance in Man (OMIM). Available from: https://omim.org/entry/175200. [Last accessed on 2022 Feb 24].  Back to cited text no. 1
    
2.
Lanza FL, Graham DY, Nelson RS, Godines R, McKechnie JC. Endoscopic upper gastrointestinal polypectomy. Report of 73 polypectomies in 63 patients. Am J Gastroenterol 1981;75:345-8.  Back to cited text no. 2
    
3.
Hsieh YH, Lin HJ, Tseng GY, Perng CL, Li AF, Chang FY, et al. Is submucosal epinephrine injection necessary before polypectomy? A prospective, comparative study. Hepatogastroenterology 2001;48:1379-82.  Back to cited text no. 3
    
4.
Hsu PI, Lai KH, Lo GH, Lin CK, Lo CC, Wang EM, et al. Sequential changes of gastric hyperplastic polyps following endoscopic ligation. Zhonghua Yi Xue Za Zhi (Taipei) 2001;64:609-14.  Back to cited text no. 4
    
5.
Lo CC, Hsu PI, Lo GH, Tseng HH, Chen HC, Hsu PN, et al. Endoscopic banding ligation can effectively resect hyperplastic polyps of stomach. World J Gastroenterol 2003;9:2805-8.  Back to cited text no. 5
    
6.
Latchford A, Cohen S, Auth M, Scaillon M, Viala J, Daniels R, et al. Management of peutz-jeghers syndrome in children and adolescents: A position paper from the ESPGHAN polyposis working group. J Pediatr Gastroenterol Nutr 2019;68:442-52.  Back to cited text no. 6
    
7.
Latchford AR, Neale K, Phillips RK, Clark SK. Peutz-Jeghers syndrome: Intriguing suggestion of gastrointestinal cancer prevention from surveillance. Dis Colon Rectum 2011;54:1547-51.  Back to cited text no. 7
    
8.
Beggs AD, Latchford AR, Vasen HF, Moslein G, Alonso A, Aretz S, et al. Peutz-Jeghers syndrome: A systematic review and recommendations for management. Gut 2010;59:975-86.  Back to cited text no. 8
    
9.
Goldstein SA, Hoffenberg EJ. Peutz-Jegher syndrome in childhood: Need for updated recommendations? J Pediatr Gastroenterol Nutr 2013;56:191-5.  Back to cited text no. 9
    
10.
Van Lier MG, Mathus-Vliegen EM, Wagner A, van Leerdam ME, Kuipers EJ. High cumulative risk of intussusception in patients with Peutz-Jeghers syndrome: time to update surveillance guidelines? Am J Gastroenterol 2011;106:940-5.  Back to cited text no. 10
    
11.
Brown G, Fraser C, Schofield G, Taylor S, Bartram C, Phillips R, et al. Video capsule endoscopy in peutz-jeghers syndrome: A blinded comparison with barium follow-through for detection of small-bowel polyps. Endoscopy 2006;38:385-90.  Back to cited text no. 11
    
12.
Gupta A, Postgate AJ, Burling D, Ilangovan R, Marshall M, Phillips RK, et al. A prospective study of MR enterography versus capsule endoscopy for the surveillance of adult patients with Peutz-Jeghers syndrome. AJR Am J Roentgenol 2010;195:108-16.  Back to cited text no. 12
    
13.
Barnard J. Screening and surveillance recommendations for pediatric gastrointestinal polyposis syndromes. J Pediatr Gastroenterol Nutr 2009;48 Suppl 2:S75-8.  Back to cited text no. 13
    
14.
Tringali A, Thomson M, Dumonceau JM, Tavares M, Tabbers MM, Furlano R, et al. Paediatric gastrointestinal endoscopy: ESPGHAN and European Society of Gastrointestinal Endoscopy Guidelines. J Pediatr Gastroenterol Nutr 2017;64:133-53.  Back to cited text no. 14
    
15.
McGarrity TJ, Kulin HE, Zaino RJ. Peutz-Jeghers syndrome. Am J Gastroenterol 2000;95:596-604.  Back to cited text no. 15
    




 

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