INTRODUCTION
Pediatric gastrointestinal endoscopy often requires narrow‐caliber endoscopes to mitigate the risk of mucosal injury, perforation, and airway compression associated with standard‐diameter equipment. The American Society for Gastrointestinal Endoscopy recommends endoscope size selection based on body size and clinical indications.1 However, therapeutic capabilities of narrow‐caliber endoscopes remain limited because most hemostatic devices are incompatible with their small working channels.
Peptic ulcer disease (PUD) is uncommon in children, with gastrointestinal bleeding representing a relatively rare cause of pediatric emergency department visits.2 Duodenal ulcers are more common than gastric ulcers in children but remain rare in infants and preschool‐aged children. Secondary ulcers associated with underlying medical conditions or drug exposure were observed more frequently than the primary ulcers in this age group.3, 4 Here, we report the case of an infant with a bleeding duodenal ulcer that was successfully treated using scissors‐type hemostatic forceps through a narrow‐caliber endoscope.
CASE REPORT
A 7‐month‐old female infant (height; 61 cm, weight; 5.1 kg) underwent left coronary pulmonary artery reconstruction because of an anomalous origin of the left coronary artery from the pulmonary artery. Postoperatively, the patient was administered with aspirin, furosemide, spironolactone, enalapril maleate, tulobuterol, and nitroglycerin.
Nine days postoperatively, she developed melena‐like vomiting and tarry stools, prompting evaluation for suspected upper gastrointestinal bleeding. Upon admission, the patient's vital signs were as follows; blood pressure 87/51 mmHg, heart rate 130 beats/min, body temperature 37.0°C, and oxygen saturation 100% on room air. She appeared pale, with no abdominal distension or tenderness.
Laboratory testing showed white blood cell count of 15,800/μL, hemoglobin level of 8.3 g/dL, hematocrit of 25.2%, platelet count of 425 × 103/μL, prothrombin time–international normalized ratio of 1.45, activated partial thromboplastin time of 27.9 s, fibrinogen level of 206 mg/dL, and D‐dimer level of 5.58 μg/mL.
Emergency esophagogastroduodenoscopy was performed under general anesthesia using a narrow‐caliber endoscope (GIF‐XP260N; Olympus; outer diameter; 5.5 mm, channel diameter; 2.0 mm). A duodenal bulb ulcer with an adherent blood clot is identified on the anterior wall. After clot removal, an exposed vessel was visible (Figure 1A,B).
Attempted placement of hemoclips using a standard‐diameter endoscope (GIF‐Q260; Olympus; outer diameter; 9.2 mm, channel diameter; 2.8 mm) was unsuccessful owing to the inability to advance the endoscope through the cervical esophagus. The narrow‐caliber endoscope was reinserted, and hemostasis was achieved using scissors‐type hemostatic forceps (SB hemostats; Sumitomo Bakelite; currently discontinued) with soft coagulation at 30 W using a VIO 3 electrosurgical unit (ERBE Elektromedizin GmbH) (Figure 2A,B).
Postoperatively, blood transfusion and proton pump inhibitor therapy with esomeprazole granules were administered. The patient was extubated the following day, resumed oral intake on postoperative day 8, and experienced no bleeding recurrence.
DISCUSSION
PUD in infants is rare, with duodenal ulcers being more frequent than gastric ulcers in pediatric populations, but remain rare in children below school age. Most infantile ulcers are secondary, with contributing factors, including nonsteroidal anti‐inflammatory drug exposure, postoperative physiological stress, trauma, sepsis, and Helicobacter pylori infection.3, 4 Although H. pylori was a differential diagnosis, testing was not performed in this case because postoperative stress following cardiac surgery combined with aspirin therapy was considered the most likely etiology.
At our institution, seven infants underwent endoscopic evaluation for suspected upper gastrointestinal bleeding, with only two requiring endoscopic hemostatic intervention. In one case, hemostasis was achieved after switching to a standard‐diameter endoscope. Contrastingly, anatomical constraints prevented standard endoscope advancement, necessitating definitive hemostasis using a narrow‐caliber endoscope.
Endoscopic management in infants presents unique challenges. Procedures require general anesthesia with endotracheal intubation, and the compliant tracheal wall in infants increases the risk of airway compression if standard‐diameter endoscopes are used.5 Consequently, narrow‐caliber endoscopes are recommended for infants and small children, with selection based on patient size and clinical indications.1, 6 However, this limits therapeutic options because most conventional hemostatic devices, including hemoclips and standard argon plasma coagulation probes, are not compatible with small working channels.5, 6
In Japan, no hemoclips that are compatible with a 2.2 mm working channel are currently available, further restricting endoscopic treatment strategies in infants. Argon plasma coagulation (APC) using a bronchial probe (1.5 mm in outer diameter) (ERBE Elektromedizin GmbH) can be performed with ultrathin endoscopes and represents a feasible and technically straightforward hemostatic option7; however, APC may be less suitable for targeted coagulation of an exposed vessel in the duodenum.
However, scissors‐type hemostatic forceps enabled precise grasping and controlled coagulation of the exposed vessel through a narrow‐caliber endoscope, resulting in effective and durable hemostasis without complications. Although APC is a potential treatment option, scissors‐type hemostatic forceps were used to achieve targeted coagulation under the anatomical and technical constraints present in this infant. Reports describing the use of scissors‐type hemostatic forceps via a narrow‐caliber endoscope for infant duodenal ulcer bleeding are limited.
Therefore, this case provides valuable clinical insights into alternative hemostatic strategies when standard devices cannot be used; however, the device used in this case is no longer available. The limited availability of such devices may reflect the small pediatric patient population and the substantial costs of development and regulatory approval, which reduce commercial incentives. Regulatory and financial support is therefore needed to promote their validation, approval, and continued availability.
This case highlights the importance of individualized endoscopic strategies in infants with gastrointestinal bleeding and underscores the urgent need for therapeutic devices specifically designed for narrow‐caliber pediatric endoscopes.
CONCLUSION
Scissors‐type hemostatic forceps represent a useful alternative for endoscopic hemostasis of bleeding duodenal ulcers in infants if standard‐diameter endoscopes and conventional devices cannot be used. Tailored endoscopic approaches based on anatomical and technical constraints are essential in pediatric patients.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
ETHICS STATEMENT
Written informed consent for the publication of this case report and accompanying images was obtained from the patient's legal guardians. Institutional review board approval was not required for this case report, in accordance with the institutional policy.