ENDOCLIPS TO TREAT SEVERE GI BLEEDING IN PEDIATRIC PATIENTS

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Background: Endoclips are metal devices that can be applied to the GI mucosa through flexible endoscopes. They have been used in adults to treat GI bleeding and luminal perforation. In pediatrics use of endoclips has been reported in the closure of gastrocutaneous fistulas. Traditional therapy for GI bleeding in pediatric patients often involves thermal techniques which expose patients to the possibility of excessive tissue injury. This series describes successful use of endoclips combined with injection of epinephrine in the treatment of severe GI bleeding in 4 pediatric patients. Methods: 4 children (12-17 yrs) with acute, transfusion dependent GI bleeding were treated with endoclips during a 3 month period. Underlying diagnoses included small bowel transplant with anastomotic ulcers, ALL with gastric ulcers, hemophagocytic lymphohistiocytosis with cecal ulcer, and empyema with duodenal ulcer. All required ICU care and 3 were on octreotide infusions. Preoperative trough Hgb ranged from 6.3-7.8 g/dL (mean 6.9). On endoscopy, 3 patients had actively bleeding ulcers, one with a visible vessel. One had anastamotic ulcers with stigmata of recent, but not active bleeding. Epinephrine (1:10,000) was injected around all lesions, and 2 or 3 endoclips were applied to the lesions, closing the defects. Results: Hemostasis was achieved in all patients. Postoperatively, trough Hgb for each patient ranged from 8.6 to 10.1 g/dL (mean 9.3) during the first 3 days. GI bleeding appeared to resolve in all patients during the postoperative period manifested by clearing of NG, rectal or ileostomy output, improvement in Hgb, and decreased transfusion requirement. Ultimately all patients required additional transfusions due to underlying diagnoses. One underwent repeat EGD with injection of epinephrine and clipping of an additional gastric ulcer 5 days later. There were no complications and no rebleeding of treated lesions. Conclusions: The use of endoclips in conjunction with epinephrine injection in the treatment of severe, acute GI bleeding is a feasible and possibly preferable alternative to thermal techniques in pediatric patients.