Apple juice as a cause of stress ulcer in a child with Fallot tetralogy

Sir, Stress ulcer (SU) is associated with many clinical conditions, but most commonly with severe stress in acutely ill patients. After major physiological stress such as brain injury, endoscopic evidence of mucosal lesions may appear within 24 h (1). Psychological stress, exogenous agents, e.g. drugs and toxins, may cause SU in adults as well as in children (2). An 18-mo-old boy was admitted to hospital due to insidious occurring melena. He had a mild form of Fallot tetralogy, diagnosed at the age of 4 mo with no hypercyanotic attacks so far. His history revealed that he was in general good condition until 4 h after a meal at which he drank about 400 ml (35 ml/kg) of freshly prepared “cloudy” apple juice, a volume he also consumed on the following day. Two days later his mother noticed melena. On the third day of the illness, when melena did not disappear, and the patient had a visibly blood-stained vomit, he was admitted to hospital. He was active but slightly cyanotic. He had no symptoms of infection or cardiac decompensation, the blood pressure and heart rate were normal. Laboratory analyses on the day of admittance and 1 mo before this illness were: erythrocytes 4.8 10/L (5.8 10/L), reticulocytes 2% (1.5%), haemoglobin 98 g/L (154 g/L), haematocrit 0.48 (0.45), leukocytes 9.6 10/L (9.4 10/L), platelet count 220 10/L (200 10/L), respectively. On the day of admittance, clotting time, prothrombin, C reactive protein, the blood pH, serum Na, K, Ca, Cl were all normal. Deviations on ECG and two-dimensional echocardiography were unchanged compared to 2 mo before admittance. Ultrasonography of the abdomen was normal. Fiberoptic gastroscopy on the day of arrival revealed a welldemarcated 10 mm ulcer without intense inflammatory reaction on the lesser curvature of the otherwise normal stomach mucosa. Duodenum and oesophagus were normal. Histological examination of biopsies from the corpus and antrum revealed no inflammation. Treatment with famotidine 15 mg b.i.d. (2.2 mg/kg/d) and sucralfate 0.5 g q.i.d. was started on the day of admission to hospital. On the 4th day of his illness he vomited once with fresh blood. Laboratory analysis revealed a drop in erythrocyte concentration to 3.8 10/L and haemoglobin to 69 g/L, so blood transfusion was performed. Haematemesis did not reappear. Visible melena disappeared on the 7th day of his illness. The treatment with famotidine was continued for 3 wk. He was discharged from hospital after 24 d in quite good condition. After 3-mo, control fiberoptic gastroscopy was performed which revealed normal stomach mucosa. Now, 4 y later, the patient is in good shape and has no gastrointestinal problems. The pathogenesis of SU is not well understood; however, it is now established that a decrease in mucosal pH below 6.5 is essential for induction of tress ulceration. This drop in mucosal pH can result from the high luminal hydrogen ion (H ‡) concentration, increased permeability of the mucosa for H ‡, or defective neutralizing ability of the mucosa (3). Gastric mucosal ischaemia is the most important risk factor for SU bleeding (4). Patients with Fallot tetralogy have arterial desaturation, polycythaemia and increased blood viscosity. These factors contribute to lowering the resistance of the stomach mucosa to aggressive factors such as hydrochloric acid and pepsin. Patients with the cyanotic form of Fallot tetralogy have hypocoagulation and thrombocytosis that can cause thrombohemorrhagic complications. Apple juice has high osmolality (870 mosM) and low pH (3.4–3.6). This is below the pH suggested for successful gastric pH control (pH > 4) in critically ill children. High acidity of the stomach contents and hypoosmolality or hyperosmolality of the liquid meal may slow gastric emptying (5). In children, consumption of large volumes of juices during a short time period may be harmful in this respect. It has been suggested that volumes exceeding 6–10 ml/kg should be avoided (6). In our case the fasting patient drank 400 ml (35 ml/kg) of apple juice over the course of a short period of time. This large volume of juice with low pH may have prolonged the gastric emptying time and exceeded gastric mucosa’s buffering capacity already reduced by permanent hypoxemia. In rats, oral administration of HCl aggravated stress ulcer in a dosedependent manner (3). Hypocoagulation may have contributed, promoting bleeding from the SU. The age of the patient (18 mo) was also supportive of SU, because most of the ulcers that occur before 5 y of age a stress ulcers. In conclusion, patients with hypoxaemia of different aetiology (in this case Fallot tetralogy) should avoid beverages of low pH, especially in large quantities.