Hot Chip Challenge: Acute Gastrointestinal Bleeding in a Pediatric Patient on Left Ventricular Assist Device

Abstract

Gastrointestinal bleeding (GIB) is the most common and potentially life-threatening bleeding complication in pediatric patients on left ventricular assist devices (LVAD), particularly under anticoagulation. We report a 13-year-old female with dilated cardiomyopathy on HeartMate 3 support who developed acute GIB after participating in a “Hot Chip Challenge,” consuming excessive spicy chips. The bleeding required blood transfusion and intensive management. This case highlights the potential impact of lifestyle factors, especially dietary choices, on GIB risk in pediatric LVAD patients.

Keywords

bleeding - coagulation/anticoagulation - cardiomyopathy - circulatory assist devices - pediatric

Introduction

Left ventricular assist devices (LVAD) therapy has emerged as well-established treatment for advanced heart failure as a bridge to transplant. One of the most common risk factors involves bleeding complications including the risk of gastrointestinal bleeding (GIB), a complication that requires meticulous management.[1] This report details the case of a pediatric patient with an LVAD, illustrating the critical interplay between diet and the heightened risk of GIB.

Case Presentation

A 13-year-old female patient (54 kg) with a diagnosed dilated cardiomyopathy, supported with a HeartMate 3 (HM3) LVAD (Abbott, North Chicago, Illinois) for 1 year was admitted to our Pediatric Cardiac Ward. The HM3 is an intracorporeal, continuous-flow device that can be implanted in older children and adolescents.[2]

Her clinical course since LVAD implantation had been complicated by a chronic driveline infection and sensitization against multiple HLA antibodies, requiring desensitization with rituximab and regular immunoglobulins.

The patient presented to the emergency department with significant pallor noticed by the family. On clinical examination, the patient was in a hemodynamically and respiratory stable condition. Pallor of the skin, mild lower leg edema, and periorbital swelling was noted. The abdomen and driveline site appeared normal, with no signs of infection or fever. LVAD assessment showed stable function, with a HM3 resistance index of 4 to 6 and rotations per minute set at 5400.

She was on dual anticoagulation with aspirin and phenprocoumon, with a target INR of 3.0 to 3.5.

Laboratory tests showed a hemoglobin drop from 12.4 to 6.6 g/dL, normal platelets of 213,000/µL, normal hepatic and renal function, and baseline NT-proBNP of 933 pg/mL. The INR was 3.1, in therapeutic target range. Further blood tests, including hemolysis parameters, were unremarkable. Additional imaging was planned, including an abdominal computer tomography (CT) scan. During the informed consent discussion, the patient disclosed having passed a large amount of melena 2 days earlier—her only episode since participating in a “Hot Chip Challenge” 3 days prior. Out of fear of negative consequences, she had not informed any caregivers. This underscores a common challenge in pediatric care: the underreporting of symptoms due to fear, embarrassment, or lack of understanding.

Following the administration of two erythrocyte concentrates hemoglobin increased to 11.8 g/dL with no subsequent decline. Anticoagulation was maintained with close INR monitoring. Further management included high-dose omeprazole therapy and dietary counselling to avoid highly processed foods. The patient remained hemodynamically stable without further bleeding. A few months later, the patient underwent successful orthotopic heart transplantation without major complications.

Discussion

Acute GIB is the most common bleeding complication in adult and pediatric patients on LVAD support.[1] Dietary factors may increase the risk of GIB, including the consumption of spicy snack foods. The social media trend known as the “Hot Chip Challenge” involves eating tortilla chips heavily spiced with capsaicin.[3] [4] [5] In addition to capsaicin, these chips often include citric acid (E330), the artificial food colorant Brilliant Blue FCF (E133), and flavor enhancers like monosodium glutamate (E621) and disodium inosinate (E631). These additives can contribute to gastrointestinal problems, including abdominal pain, mucosal irritation, reflux, and bleeding. The extremely sour nature of the chips suggests a high concentration of acidifiers, which may cause direct chemical injury to the gastric mucosa and impair normal gastric function.

At the time of the bleeding event, dual antithrombotic therapy including aspirin was the standard of care for all pediatric patients with a HM3 device. Since then, aspirin has been removed from the regimen in adolescents and adults due to increased risk of bleeding complications. While overtreatment was considered, the absence of recurrent GIB before or after the episode makes this less likely. Instead, the ingestion of spicy chips was considered the most probable trigger for the bleeding event.

Due to the marked decrease in hemoglobin, the patient received a blood transfusion. While clinically necessary, transfusion carries the risk of HLA alloimmunization, potentially impacting further transplant outcomes—particularly in a patient with preexisting sensitization. Additionally, potential risks from ionizing radiation and contrast exposure associated with the planned CT scan were ultimately avoided following the resolution of melaena.

Conclusion

This case emphasizes the significance of dietary choices and the potential risk posed by certain food ingredients in this vulnerable patient population. Improved understanding of common snack food ingredients may help identify harmful additives for children and adolescents with elevated bleeding risk, particularly patients on VADs before cardiac heart transplantation. A comprehensive approach that includes close monitoring of anticoagulation levels, dietary education, and vigilance for signs of gastrointestinal distress is crucial.

Conflict of Interest

None declared.

• References

• 1 O'Connor MJ, Shezad M, Ahmed H. et al. Expanding use of the HeartMate 3 ventricular assist device in pediatric and adult patients within the Advanced Cardiac Therapies Improving Outcomes Network (ACTION). J Heart Lung Transplant 2023; 42 (11) 1546-1556
• 2 Mehra MR, Naka Y, Uriel N. et al; MOMENTUM 3 Investigators. A fully magnetically levitated circulatory pump for advanced heart failure. N Engl J Med 2017; 376 (05) 440-450
• 3 Trial by fire: Extremely spicy food can be particularly harmful to children's health [press release]. Berlin: German Federal Institute for Risk Assessment, 7.09.2023; 2023
• 4 Nopanitaya W, Nye SW. Duodenal mucosal response to the pungent principle of hot pepper (capsaicin) in the rat: light and electron microscopic study. Toxicol Appl Pharmacol 1974; 30 (01) 149-161
• 5 Myers BM, Smith JL, Graham DY. Effect of red pepper and black pepper on the stomach. Am J Gastroenterol 1987; 82 (03) 211-214

Publication History

Received: 25 August 2025

Accepted: 13 October 2025

Article published online:
01 December 2025