Treatment of a Cushing's ulcer in a 7-y.o. child after a tumor (medulloblastoma) removal in ventricle IV

BACKGROUND: Cushing's ulcer is a stress ulcer in the stomach or duodenum which basic etiological factor is increased intracranial pressure. The increased intracranial pressure is caused, most often, by intracranial neoplasms, cranial-cerebral injury or previous neurosurgical interventions. Cushing's ulcers are usually solitary and deep, often complicated with recurrent gastrointestinal bleedings and less often with perforations. In cases of suspected perforation in a complex anatomical localization (posterior wall of the duodenum), the method of choice according to the world literature is computed tomography with intravenous contrast. Subsequently, after brief preoperative preparation, indications for laparoscopy or laparotomy with subsequent ulcer closure are determined. In the absence of free gas in the abdominal cavity, the "gold standard" for diagnosis and treatment is esophagogastroduodenoscopy. During esophagogastroduodenoscopy, it is necessary to visualize the source of gastrointestinal bleeding and determine if it is ongoing. In cases of ongoing gastrointestinal bleeding, endoscopic hemostasis is performed. If it is not possible to establish the source of bleeding and/or if local hemostasis attempts are unsuccessful, endovascular arterial embolization is recommended. If all minimally invasive methods are ineffective, radical methods such as laparoscopy or laparotomy with visualization of the source of bleeding, cessation of bleeding, and ulcer closure are employed.

Clinical Case Description. This clinical case demonstrates the severity and unpredictability of the clinical course of Cushing's ulcer complicated by gastrointestinal bleeding. The patient underwent multiple hemostatic procedures through esophagogastroduodenoscopy and arterial embolization. However, despite all minimally invasive treatment methods, the patient's condition required radical surgical treatment.

CONCLUSION: There is no information in the world literature about the algorithm for managing recurrent gastrointestinal bleeding in the context of Cushing's ulcer. The authors recommend to covert to more radical treatment only after all minimally invasive techniques turned to be ineffective.