Images in Paediatrics
Hemodynamic shock secondary to massive duodenal ulcus
Shock hemodinámico secundario a ulcus duodenal masivo
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Electrocardiogram conducted at the time the exercise challenge test was interrupted due to chest pain 8 min after starting. ST segment elevation measuring 3 mm in V2–V3 leads and 1 mm in V4 (red rectangle around V2–4), and 1–2 mm ST segment depression with T wave inversion in leads V5 and V6 (blue rectangle around V5–6), compatible with ischaemia in the region supplied by the anterior descending artery (ADA). The pattern normalised completely after 4 min of rest.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Bottom. Three different views from the same coronary CT angiography showing myocardial bridging, 8 mm in length and 4.5 mm in width, in the medial segment of the ADA (white arrows). The course of the ADA leaves the surface of the heart to tunnel into the myocardium of the left ventricle in the different views. 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The patient had vomited stomach contents mixed with blood between both episodes.</p><p id="par0010" class="elsevierStylePara elsevierViewall">On arrival, he was unstable, and the following tests were ordered: head CT scan, complete blood count and panel, and upper gastrointestinal endoscopy (UGIE). The latter revealed a large, excavated defect in the duodenal bulb (Forrest Ib lesion) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and oesophagitis (Los Angeles grade D). Massive bleeding developed during the procedure, prompting performance of resuscitation manoeuvres and injection of adrenaline and polidocanol in the preserved mucosa. Due to the persistence of bleeding, we performed an angiography with embolization of the gastroduodenal artery (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), after which there was no further evidence of bleeding. Treatment with high-dose proton pump inhibitors (PPIs) was initiated. Further evaluation ruled out malignant disease, <span class="elsevierStyleItalic">Helicobacter pylori</span> was not detected the histological examination, and the basal serum concentration of gastrin and the findings of the single-photon emission CT scan were normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patient remained in treatment for 7 months, with a follow-up UGIE, after discontinuation of PPI treatment, evincing antral gastritis with features suggestive of <span class="elsevierStyleItalic">H. pylori</span> infection, although the cultures remained negative. Serologic testing for detection of <span class="elsevierStyleItalic">H. pylori</span> was ordered and turned out positive. Given the high frequency of <span class="elsevierStyleItalic">H. pylori</span> associated with this condition, the decision was made to start empiric eradication therapy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Giant duodenal ulcers are rare but potentially severe lesions in the paediatric age group.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Infection by <span class="elsevierStyleItalic">H. pylori</span> is the most frequent cause, and should be tested for in every case.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Previous meeting: the case was presented as an oral communication at the II Virtual Scientific Meeting of the Sociedad de Pediatría de Asturias, Cantabria y Castilla y León (SCCALP), held online on November 4–5, 2021.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 559 "Ancho" => 605 "Tamanyo" => 61306 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Duodenal ulcer with active bleeding.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 426 "Ancho" => 905 "Tamanyo" => 48681 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Visualization of irregularity in the gastroduodenal artery wall before proceeding to the gastroepiploic artery. Coil embolization.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Helicobacter pylori</span> infection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Cho" 1 => "A. Prashar" 2 => "N.L. Jones" 3 => "S.F. Moss" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.gtc.2021.02.001" "Revista" => array:6 [ "tituloSerie" => "Gastroenterol Clin North Am" "fecha" => "2021" "volumen" => "50" "paginaInicial" => "261" "paginaFinal" => "282" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34024441" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Peptic ulcer disease in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Dohil" 1 => "E. Hassall" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/bega.1999.0059" "Revista" => array:6 [ "tituloSerie" => "Baillieres Best Pract Res Clin Gastroenterol" "fecha" => "2000" "volumen" => "14" "paginaInicial" => "53" "paginaFinal" => "73" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10749089" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Joint ESPGHAN/NASPGHAN guidelines for the management of <span class="elsevierStyleItalic">Helicobacter pylori</span> in children and adolescents (update 2016)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.L. Jones" 1 => "S. Koletzko" 2 => "K. Goodman" 3 => "P. Bontems" 4 => "S. Cadranel" 5 => "T. Casswall" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Pediatr Gastroenterol Nutr" "fecha" => "2017" "volumen" => "64" "paginaInicial" => "991" "paginaFinal" => "1003" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000010000000001/v1_202401141514/S2341287923002867/v1_202401141514/en/main.assets" "Apartado" => array:4 [ "identificador" => "77701" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Images in Paediatrics" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000010000000001/v1_202401141514/S2341287923002867/v1_202401141514/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287923002867?idApp=UINPBA00005H" ]
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