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Gastric antral vascular ectasia (GAVE) associated with mTOR inhibitors has been reported in adult literature, 1 2 but to our knowledge there is no published data of targeted drug therapies associated with severe gastrointestinal haemorrhage in paediatric patients. GAVE itself is considered a very rare cause of gastrointestinal bleeding in children.We present a case of Everolimus- associated gastrointestinal bleeding in a paediatric patient.A 15-year-old boy with a background of Tuberous sclerosis, cardiac rhabdomyoma, seizures and recurrent fractures presented with a life-threatening gastrointestinal bleed. He had been treated with Everolimus since 2014 as part of drug trial for cardiac rhabdomyoma.Whilst in hospital for a lower respiratory tract infection, he developed hematemesis and required blood transfusion (Hb dropped from 92 to 81 g/L). He underwent OGD with banding of vascular lesions in his stomach by adult gastroenterologists. He developed further melena, hence he was transferred to our Unit where he was treated with octreotide infusion. In view of on-going melena and oxygen requirement, he underwent endoscopic reassessment that revealed generalised oozing in gastric antrum (figure 1). Haemospray was applied which stopped the oozing (figure 2). He dropped his haemoglobin again to 75 g/L (from 88 g/L) with worsening of his respiratory and neurological status. He was transferred to high dependency unit and received another blood transfusion and parenteral nutrition. At this point, endoscopic reassessment under GA wasn’t deemed safe. Octreotide infusion (5 mcgrams/kg/minute) continued. Computed Tomography scan of the abdomen ruled out vascular anomalies. Detailed review of his medical background led to literature search on Everolimus and its association with gastrointestinal bleeding. Everolimus was withheld. As he had tolerated the mTOR inhibitor for 10 years, the neurology team were keen to restart it. 72 hours after restarting Everolimus, he dropped his haemoglobin from 93 to 75 g/l. Following MDT discussion, everolimus was discontinued.Endoscopic re-evaluation revealed vascular lesions and two band ligators (7 mm) were applied distally to proximally in gastric antrum (figure 3). Subsequently, he was successfully weaned off octreotide and was re-established on oral diet without any further gastrointestinal bleeding in the next 6 months.We successfully treated GAVE with band ligation in a paediatric patient who was treated with mTOR inhibitor. GAVE is considered to be associated to mechanical stress caused by altered gastric motility and gastric dysfunction that leads to submucosal fibromuscular hyperplasia and dilation of mucosal capillaries. Everolimus increases the gastric motility which may contribute to the development of GAVE. We aim to raise the awareness of this rare adverse effect which can be a challenging cause of severe gastrointestinal haemorrhage in children.Abstract OC39 Figure 1Endoscopy showing previous bands and oozing in the antrumAbstract OC39 Figure 2Application of haemosprayAbstract OC39 Figure 3Application of bands to the vascular lesions in the stomachReferences Fujihara S, Mori H, Kobara H, et al. Life-threatening gastrointestinal bleeding during targeted therapy for advanced renal cell carcinoma: a case report. BMC Nephrology. 2013;14(141). doi: 10.1186/1471-2369-14-141. [DOI] [PMC free article] [PubMed] [Google Scholar]Assi H, Abdel-Samad N. Severe gastrointestinal hemorrhage during targeted therapy for advanced breast carcinoma. Current Oncology 2014;21(5):732–735. doi: 10.3747/co.21.2038.Tsunematsu M, Haruki K, Saito R, Watanabe M, Masubuchi M, Yanaga K. Severe gastrointestinal hemorrhage related to everolimus: a case report. Clin. J. Gastroenterol. 2019;12:552–555. doi: 10.1007/s12328-019-00978-8.Hsu WH, Wang YK, Hsieh MS, et al. Insights into the management of gastric antral vascular ectasia (watermelon stomach). Therap. Adv. Gastroenterol. 2018;11:1756283x17747471.