Early Gastrointestinal Bleeding after Kasai Portoenterostomy: A Single-center Experience with Etiology and Management

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A BSTRACT Purpose: To evaluate the etiological spectrum, diagnostic approach, management strategies, and clinical outcomes of early gastrointestinal (GI) bleeding occurring within 30 days following Kasai portoenterostomy (KPE) in infants with biliary atresia. Materials and Methods: A retrospective review was conducted of 201 infants who underwent KPE between January 2016 and September 2025 at a tertiary care center. Early GI bleeding was defined as any bleeding episode within 30 postoperative days (PODs). Clinical presentation, laboratory parameters, imaging findings, interventions, and outcomes were analyzed. Diagnostic evaluation included coagulation and sepsis screening, Doppler ultrasonography, computed tomography (CT) angiography, and upper GI endoscopy, guided by the pattern of bleeding. Results: Seven infants (3.4%) developed early GI bleeding at a median of 9 days (range: 3–20 days). Presentations included melena (4/7, 57%), hematemesis (2/7, 29%), and hemoperitoneum (1/7, 14%). Right hepatic artery pseudoaneurysm (RHAPA) was identified in 2 (28.6%) of 7 patients and represented an uncommon but clinically significant vascular cause of early postoperative GI bleeding which was successfully treated with transcatheter embolization. Other etiologies included stress gastritis, sepsis-associated coagulopathy, and ileoileal intussusception. No etiology was identified in two cases. At a mean follow-up of 32 months, 3 (42.9%) of 7 patients in the bleeding cohort died. Conclusion: Early GI bleeding following KPE is uncommon but clinically significant. Prompt, structured evaluation with early CT angiography should be considered in hemodynamically stable infants with severe, recurrent, or unexplained GI bleeding, particularly when a vascular cause is suspected, as it may facilitate identification of treatable vascular lesions such as RHAPA.