Grand Rounds

Hematemesis and malena

Medical Sciences Department, Pediatric Oncall, Mumbai, India

Clinical Problem :
A 3 years old boy born of non consanguineous marriage presented with hematemesis and malena 1 year ago and again with malena 6 months ago for which child required blood transfusion. There is no jaundice or bleeding from any other site. On examination, he is pale. There is no jaundice and spleen is just palpable. Other systems are normal. Investigations are depicted in Table 1.
• Hemoglobin = 6.7 gm, dl, WBC = 6400, cumm, platelets = 1,27,000, cumm
• Bilirubin = 0.8 mg, dl, SGOT = 51 IU, L, SGPT = 67 IU, L, Total proteins = 6.9 gm, dl,
Albumin = 3.9 gm, dl.
• Prothrombin time, partial thromboplastin time = Normal
• Ultrasound abdomen = Normal.

What is the cause of hematemesis and malena in this child _?

Discussion :
This child has hematemesis and malena with just palpable spleen, mildly elevated liver enzymes, thrombocytopenia, Thus one should consider differential diagnosis of extrahepatic portal hypertension, chronic liver disease, hemolytic anemia with hypersplenism and bleeding disorder. For chronic liver disease, the liver should be palpable. A non-palpable liver would suggest shrunken liver and cirrhosis. However, then patient should have hypoalbuminemia and coagulopathy which are all normal. Thus, in this child, chronic liver disease seems unlikely. Hemolytic anemia with hypersplenism would imply a large spleen and pancytopenia. In this child, spleen is just palpable and there is no pancytopenia so hypersplenism is also unlikely. In case of bleeding disorder, though this child has low platelet count, they are not that low to cause bleeding. Also, prothrombin time and partial thromboplastin time are normal. Thus, platelet function defects could be the cause of bleeding. However, bleeding disorders should cause bleeding in other areas as well and there should be petechiae or other signs of bleeding. Thus, bleeding disorder should not be considered as primary diagnosis. Extrahepatic portal hypertension can cause hematemesis and malena. Mildly elevated liver enzymes can occur due to portal biliopathy. In this child esophagcogastroscopy and colour doppler of abdomen should be done. Colour doppler showed portal cavernoma following portal vein thrombosis and multiple collaterals in periportal region suggestive of portal cavernoma. Thus, this child was diagnosed as extrahepatic portal hypertension.

Correct Answers :  yes 40%
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