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Life‐threatening haemorrhage from a gastric Dieulafoy lesion in a child with haemophilia

A 5-year-old boy had been diagnosed with haemophilia A at 3 months of age, when he had developed a severe haematoma following intramuscular injections. He had been treated on numerous occasions with factor VIII (FVIII) for minor spontaneous bleeds and had developed inhibitors to FVIII. With little prodrome, he experienced a massive haematemesis. On arrival to hospital he was shocked and pale with haemoglobin of 3 g dL. Resuscitation was commenced with whole blood, fresh frozen plasma and factor IX replacement. The child’s haemodynamic status stabilized, however, within 12 hours of admission, he had two further episodes of massive haematemesis. Following the third haematemesis, an episode of severe sinus bradycardia was noted. Again he responded to resuscitation and was referred for a paediatric surgical opinion. By the time of referral a total of 1400 mL of whole blood had been transfused. Fibreoptic endoscopy was performed under general anaesthesia. A large amount of fresh blood was present in the stomach and a small blood vessel was seen protruding from an otherwise intact mucosa in the area of the incisura. A small fibrin plug was present over the bleeding vessel, which was actively bleeding. We proceeded to laparotomy via an upper midline incision, the bleeding point was confirmed to be a Dieulafoy lesion and oversewn. The child made an uncomplicated recovery.