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Operative management of stress ulcers in children
Insights
Surgical management of pediatric stress ulcers is debated. Partial gastrectomy offers the best protection against re-bleeding in children with stress ulcers, while simpler procedures suffice for single ulcers or perforations.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Critical Care Medicine
Background:
- Operative management of stress ulcers in children remains controversial.
- Stress ulcers in children are often associated with severe underlying medical conditions.
Purpose of the Study:
- To review the surgical outcomes for pediatric patients treated for stress ulcers.
- To evaluate the effectiveness of different surgical interventions for bleeding and perforated stress ulcers in children.
Main Methods:
- Retrospective review of 10 pediatric patients undergoing 11 operations for stress ulcers between 1969 and 1981.
- Analysis of patient diagnoses, operative procedures, and outcomes, including complications and mortality.
Main Results:
- Multiple ulcerations were common in critically ill children.
- Partial gastrectomy with or without vagotomy was associated with better control of recurrent bleeding.
- Lesser procedures were effective for solitary ulcers or perforations.
- Arterial embolization or vasopressin infusion showed unreliable results in controlling bleeding.
- Two deaths (20%) occurred in patients who underwent gastrectomy.
Conclusions:
- Partial gastrectomy provides maximal protection against recurrent bleeding in pediatric stress ulcers.
- Simpler surgical procedures are suitable for solitary bleeding ulcers or perforations.
- Endoscopic or interventional radiological methods for bleeding control were found to be unreliable in this series.
Abstract:
The operative management of stress ulcer in children is controversial. Between the years 1969 and 1981, ten children were operated on at the Babies Hospital for stress ulcer. Their illnesses included connective tissue disorders (3), sepsis (2), Reye's syndrome (1), hemolytic uremic syndrome (1), leukemia (1), closed head injury (1), and renal failure (1). In those with bleeding (8), aggressive conventional medical management was attempted prior to operation. Four children also received intravenous cimetidine. Four patients underwent embolization of a feeding artery and/or selective vasopressin infusion. In those patients who perforated (2), operation was performed after a brief period of resuscitation. Ten patients underwent 11 operations. In those who bled, multiple ulcerations were the most common finding. Operative procedures consisted of partial gastrectomy and vagotomy (4), partial gastrectomy alone (2), and vagotomy and pyloroplasty (2). One child who underwent vagotomy and pyloroplasty required partial gastrectomy for recurrent bleeding. Of the two children who perforated, one was managed by plication and the other by partial gastrectomy. There were two deaths (20%), both occurring in patients who had undergone gastrectomy. One survivor has mild dumping. This experience suggests that in children (1) stress ulcers are commonly multiple when associated with major medical illnesses; (2) partial gastrectomy with or without vagotomy affords maximum protection against recurrent bleeding; (3) lesser procedures are effective for solitary bleeding duodenal ulcers or perforation; and (4) selective arterial embolization or vasopressin infusion are unreliable methods for controlling bleeding.