Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 1998  |  Volume : 4  |  Issue : 3  |  Page : 179-181
Unusual cause of hematemesis and melena


Faculty of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia

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Date of Submission13-Oct-1997
Date of Acceptance27-Apr-1998
 

How to cite this article:
Al Rashed A. Unusual cause of hematemesis and melena. Saudi J Gastroenterol 1998;4:179-81

How to cite this URL:
Al Rashed A. Unusual cause of hematemesis and melena. Saudi J Gastroenterol [serial online] 1998 [cited 2019 Aug 19];4:179-81. Available from: http://www.saudijgastro.com/text.asp?1998/4/3/179/33916


Recognition of the cause of hematemesis and melena in children is a challenging problem because of the multiple, often nonspecific, symptoms[1]. The main causes of gastrointestinal hemorrhage in children are duodenal ulcer, esophageal varices, stress ulcer, reflux esophagitis, aspirin-induced gastritis, gastric ulcer[2],[3],[4], nonsteroidal anti inflammatory drugs[5] and Henoch-Schonlein purpura[6]. One should not overlook rare causes such as Still's disease[7], duodenal lymphangiectasia[8], Peutz-Jegher syndrome[2], and Mallary-Weiss syndrome[9].

The causes of GI bleeding in children in developing countries are different from those in developed countries where variceal bleeding due to extrahepatic portal venous obstruction is the most common cause[10]

Removal of uvula is a common procedure for throat problems in Nigeria and some other African countries by traditional healers[12],[13]. Prual et al found that 19.6% of children in their survey in Niamey, capital of Nigeria, had undergone uvulectomy by the age of 5[14]. Uvulectomy is performed as a ritual custom as being done by tribes of bedouins in the south of Sinai[15]. Others believe that it cures vomiting, diarrhea, anorexia, child rejection of breast and growth retardation[14].

Unusual causes should be kept in mind and a high index of suspicion should be there in order not to miss such cases. The medical services in Saudi Arabia have improved tremendously over the past two decades and health centers are easily accessible to more than 93% of the population[11]. An unusual cause of hematemesis and melena following uvulectomy performed by a barber is reported. This occurred in a barber's shop about 200 meters near a major teaching hospital in Riyadh.


   Case Report Top


A three-year-old Saudi girl was brought by her parents to the emergency room at King Abdulaziz University Hospital (KAUH) in Riyadh with the chief complaint of hematemesis and passage of melena stools. The girl reported to have vomited three times in the preceding 24 hours. Vomitus was dark red in colour and passed melena stool four times. Stool was soft and did not contain mucus. There was no history of abdominal discomfort or pain. They volunteered that she had a history of poor appetite and that of recurrent sore throats. They denied any history of epistaxis or bleeding tendencies as well as that of trauma. She was not on any medication and had no known food allergies.

The birth and neonatal history were uneventful. She had previous admission at the age of 17 months for bronchial asthma and acute gastroenteritis from which she recovered. There was no history of bleeding tendencies in the family. The parents are not of a consanguineous marriage. The father works as a clerk with a reasonable income and the mother was a housewife.

On physical examination, her weight was 12 kgs. and her height 89 cm, both correspond to 5th percentile respectively. The temperature was 36.7°C. The pulse rate was 140/minute, was regular and non-collapsing. The respiratory rate was 40/min. Blood pressure was 90/60 mm/hg. The oral cavity was filled with fresh blood and it was difficult to visualize the tonsils.

Abdominal examination revealed a soft abdomen with no distention or scar and it was not rigid nor tender. Spleen, liver kidneys and masses were not palpable, there was no ascites and bowel sounds were normal, the genitalia and rectal examination were normal apart from dark stool. Other systems examination were unremarkable.

CBC on the day of admission showed hemoglobin of 3.9 g/dl, hematocrit of 11.9%, platelet count of 410,000/ml WBC of 12,300/ml. PT, PTT, FDPG, Na, K, BUN, creatinine° and liver enzymes all were normal. A diagnosis of acute gastrointestinal bleeding was entertained and the child was admitted at King Khalid University Hospital in Riyadh where she required repeated blood transfusion on three occasions, each consisted of 200cc, 150cc and 120cc of fresh blood consecutively after which she was stabilized. Her post transfusion hemoglobin remained normal.

On further questioning, the father admitted that he had taken the child to a traditional healer because of the recurrent sore throat and poor appetite. The traditional healer according to the father was a barber whose shop was close to the hospital and he performed the surgery for about 35 pound sterling. The procedure was performed in the afternoon and she came back home next morning.


   Discussion Top


The uvula is a small soft structure hanging from the free edge of the soft palate in midline above the root of the tongue. Histologically it contains muscle, connective tissue and mucus membrane[16]. Its blood supply comes from the ascending palatine branch of the facial artery and ascending pharyngeal artery[17]. It rarely presents a problem to the child and infections are infrequent[18]

This case shows that the clinician can be deceived easily but with good index of suspicion and good history taking one could get into the root of this problem. If we did not dig into the history and lately discovered that the father took the child to the traditional healer, otherwise, rare causes of acute gastrointestinal bleeding will be considered. The importance of history taking cannot be over­emphasized in all divisions of medical practice.

Otolaryngologist practicing especially in the tropics and developing world should be aware of this dangerous attitudes and practice. It is common practice in many areas of Africa for traditional healers to remove the uvula to prevent infections and various disorders associated with sore throat[12]

Despite the fact that health centers are easily accessible to more than 93% of the population of Saudi Arabia, folk medicine, manual tonsillectomy and uvulectomy are still widely practiced in the Kingdom[11]. Among the Bedouins in the south of Sinai, partial or total removal of the uvula is usually performed on both boys and girls during the first two years of life as ritual custom[15]. They also stated the effect on health in general and on speech. The traditional surgery is not without its various complications, however it's the complication that brings the patients to the hospital. In an extensive study of this practice in Nigeria, Ijaduola was able to show that these traditional healers are usually barbers by profession and only practice surgery on a part-time basis[13]. Although he stated that most of the patients do well but some have serious complications and even death[19],[20]. The most common complications is severe postoperative bleeding like what happened in our patient.

Tetanus is a serious complication as shown by Eregie from Nigeria in 1994 where the association between neonatal tetanus, death and traditional surgery was highly significant and uvulectomy was the most frequently performed traditional surgery[21]

This association is not seen here in Saudi Arabia because the immunization drive and the use of potent vaccines has achieved its success as almost all children are fully immunized.

Other complications of this malpractice include palatal palsy, cellulitis of the neck, peritonsillar and parapharyngeal abscess, upper airway obstruction and pharyngo-laryngocele with pneumothorax[22]

Prual et al had shown that severe complications of uvulectomy represented 7.8/1000 cases of hospitalization for children under 15 years of age in the capital of Nigeria[14]. The cut piece of uvula may pass further down the respiratory tract[14]

Late consequences include a change in shape and symmetry of the arches of the palate and it may affect the speech[15].

In summary, our patient developed serious gastrointestinal bleeding secondary to unaccepted practice of traditional healer. We highly recommend a periodic and unscheduled inspection of barber shops so as to put an end to this barbaric practice.

 
   References Top

1.Kirschner BS. Peptic ulcer disease in children. Compr. Ther. 1976;2:53-60.  Back to cited text no. 1    
2.Stevenson RJ. Gastrointestinal bleeding in children. Surg. Clin. North Am. 1985;65:1455-80.  Back to cited text no. 2    
3.Cox K, Ament ME. Upper gastrointestinal bleeding in children and adolescents. Pediatrics 1979;63:408-13.  Back to cited text no. 3  [PUBMED]  
4.Larrosa-Haro A, Coello-Ramirez P. Usefulness of endoscopy in the differential diagnosis of hemorrhage of the upper digestive tract in children. Bol. Med. Hosp. Infant. Mex. 1992;49:743-9 (Abstract).  Back to cited text no. 4    
5.Ivey KJ. Gastrointestinal intolerance and bleeding with non­narcotic analgesics. Drugs 1986;4:71-89.  Back to cited text no. 5    
6.Katz S, Borst M, Seekri I, Grosfeld JL. Surgical evaluation of Henoch-Schonlein purpura. Experience with 110 children. Arch. Surg. 1991;126:849-53.  Back to cited text no. 6    
7.Wang YJ, Lee YP, Chi CS. Still's disease: experience in 12 children. Acta. Pediatr. Sin. 1993;32:390-7.  Back to cited text no. 7    
8.Perisic VN, Kokai G. Bleeding from duodenal lymphangiectasia. Arch. Dis. Child. 1991;66:153-4.  Back to cited text no. 8    
9.Countryman D, Norwood S, Andrassy RJ. Mallory-Weiss syndrome in children. South. Med. J. 1982;75:1426-7.  Back to cited text no. 9    
10.Yachha SK, Khanduri A, Sharma BC, Kumar M. Gastrointestinal bleeding in children. J. Gastroenterol Hepatol. 1996;11:903-7.  Back to cited text no. 10    
11.Abdullah MA. Traditional practices and other socio-cultural factor affecting the health of children in Saudi Arabia. Ann Trop Pediatr 1993;13:227-32.  Back to cited text no. 11    
12.Hartley BE and Rowe-Jones J. Uvulectomy to prevent throat infections. J Laryngol Otol. 1994;108:65-6.  Back to cited text no. 12    
13.Ijaduola Gt. Uvulectomy in Nigeria. J. Laryngol Otol 1981;95:1127-33.  Back to cited text no. 13    
14.Prual A, Gamatie Y, Djakounda M, Huguet D. Traditional uvulectomy in Niger: a public health problem. Soc Sci Med. 1994;39:1077-82.  Back to cited text no. 14    
15.Nathan H, Hershkoritz I and Arensbury B, et al. Mutilation of the uvula among Bedouins of the South Sinai. Isr J Med Sci 1982;18:774-8.  Back to cited text no. 15    
16.Taber's Cytopedic Medical Dictionary. F. A. Davis Company 1981;p 1522.  Back to cited text no. 16    
17.Berkoritz BJ. Moam Textbook of Head and Neck Anatomy. Wolfe Medical Publications Ltd. 1988;p297.  Back to cited text no. 17    
18.Behrman and Vaoghan, Nelson Textbook of Pediatrics. W. B. Saunders Co. Thirteenth Edition 1987;p872.  Back to cited text no. 18    
19.Adekeye EO, Kwamin F, Ord RA. Serious complications associated with uvulectomy performed by a "native doctor". Trop Doct. 1984;14:160-1.  Back to cited text no. 19    
20.Nalin DR. Death of child submitted to uvulectomy for diarrhea. Lancet. 1985;1:643.  Back to cited text no. 20    
21.Eregie CO. Uvulectomy as an epidemiological factor in neonatal tetanus mortality: observations from a cluster survey. West Afr J Med 1994;13:56-8.  Back to cited text no. 21  [PUBMED]  
22.Olu-Ibekwe A. Complications of the "treatment" of tonsillar infection by traditional healers in Nigeria. J Laryngol Otol. 1983:97:845-9.  Back to cited text no. 22    

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Correspondence Address:
Abdulaziz Al Rashed
Department of Pediatrics (39), College of Medicine & KKUH, P.O. Box 2925, Riyadh 11461
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864770

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