Upper Gastrointestinal Bleeding, Pediatric

Upper gastrointestinal bleeding (UGIB) is defined as bleeding in the GI tract that occurs proximal to the ligament of Treitz.

The classic clinical symptom of UGIB is hematemesis, consisting of either bright red or "coffee grounds " ЕЃ appearing blood.

Other symptoms of UGIB include melena, occult blood loss, as well as hematochezia with rapid, severe bleeds.

When hematemesis is suspected, a clinician must exclude non-GI causes, including hemoptysis (coughing up blood), nose bleeds, and bleeding from the mouth and pharynx.

Epidemiology

Most large, prospective studies of UGIB in children have assessed the incidence in pediatric critical care settings to range from 6.4 to 25% of admissions.

80% of UGIB resolve spontaneously.

Etiology

Neonatal period (birth to 1 month)

Swallowed maternal blood

Necrotizing enterocolitis

Duodenal or antral webs

Hemorrhagic disease of the newborn

Esophagitis

Gastritis

Stress ulcer

Foreign body irritation

Vascular malformation

GI malformation

Infancy (1 month to 2 years)

Esophagitis/gastritis

Stress ulcer

Mallory-Weiss tear

Pyloric stenosis

Vascular malformation

Duplication cysts

Metabolic disease

Preschool age (2 " Гґ5 years)

Esophageal varices

Esophagitis/gastritis/ulcer

Foreign body/bezoar

Mallory-Weiss tear

Vascular malformation

Meckel diverticulum

School age (>5 years)

Esophageal varices

Infection

Esophagitis/gastritis/ulcer

Mallory-Weiss tear

Inflammatory bowel disease

Drugs: NSAIDS,α-adrenergic antagonists

Helicobacter pylori

All ages: liver failure " Г¶coagulopathy, Henoch-Sch Гў Г‚nlein purpura

Risk Factors

Liver disease may cause portal hypertension and/or coagulopathy.

Renal disease may cause gastritis or angiodysplasia.

Renal failure or cirrhosis may cause gastric antral vascular ectasia.

Recent trauma or stress (e.g., burns, head trauma, surgery) may be associated with a stress ulcer or gastritis.

General Prevention

Avoid or minimize the use of drugs that can lead to peptic ulcers, for example, NSAIDs and aspirin.

In patients with chronic GI conditions, optimize therapy and monitoring.

Correct coagulopathy.

Prophylactic medical or endoscopic therapy is beneficial for patients with known variceal bleeding.

Diagnosis

Approach to the Patient

The initial evaluation of patients presenting with GI bleeding should focus on assessing vital signs, obtaining a history of present illness, as well as pertinent medical history, performing a physical examination, and lab testing.

General goals: Determine location of the bleeding and etiology, begin stabilization, and start treatment.

Phase 1: Determine whether the emesis contains blood versus nonblood substances. Red food coloring, fruit-flavored drinks, juices, vegetables, and some medicines may resemble blood. A pH-buffered Gastroccult test can be used to identify blood in the vomitus.

Phase 2: Assess severity of bleeding. Is there a change in vital signs, hematocrit, BP, capillary filling, pulse?

Phase 3: Stabilize patient, and decide if emergency treatment or referral is needed.

History

GI symptoms:

Emesis prior to hematemesis may suggest Mallory-Weiss tear.

Odynophagia and GERD may suggest esophageal ulcer.

Epigastric pain may suggest peptic ulcer.

Characteristics of UGIB:

Color of blood: may help determine whether bleeding is active

Emesis: bright red blood versus coffee ground

Stool: melena versus maroon colored versus hematochezia

Amount of blood

May indicate severity of bleeding (i.e., drops vs. 1 teaspoon vs. 1 tablespoon)

Duration of symptoms

May help determine if this is an acute or chronic issue

Medication history:

The patient 's current or recently used medications may help determine the cause.

Gastrotoxic medications, such as NSAIDs and aspirin, as well as anticoagulant medication use may be implicated.

In addition, a history of medications in the house should also be obtained due to possible accidental ingestion in younger children.

Prior history of UGIB

May help determine the location of current bleed

If the prior bleed was recent, this may facilitate timely specialty consultation with gastroenterology, surgery, and/or interventional radiology.

Prior GI history

Gastroesophageal reflux, peptic ulcer disease, and/or previous GI surgery are risk factors for UGIB. May suggest symptoms are due to recurrence of disease

Social history

A history of alcohol use could be associated with gastritis or Mallory-Weiss tear

Physical Exam

Immediately assess hemodynamic stability:

Heart rate: Tachycardia may be an early sign of intravascular volume depletion.

Blood pressure: Hypotension is a late sign of volume depletion and may not be present even with significant blood loss, as vasoconstriction maintains BP until decompensation occurs.

In the setting of normal blood pressure, obtain orthostatic BP.

Oxygen saturation: Decreased arterial saturation values may be due to decreased oxygen-carrying capacity.

Evaluate for signs of shock:

Vital sign derangement (as listed earlier)

Cool clammy extremities

Poor mentation

Abdomen

Evaluate bowel sounds for evidence of possible bowel obstruction.

Assess for abdominal tenderness, which may suggest peptic disease.

Evaluate for ascites, which may suggest liver disease.

Evaluate for signs of chronic liver disease of portal hypertension:

Hepatomegaly

Splenomegaly

Spider angioma

Caput medusa

Palmar erythema

Ascites

Rectal examination

Heme-positive stool may or may not be present.

If positive, supports diagnosis of UGIB

Skin

Petechiae, ecchymosis, or hemangiomas may suggest a coagulopathy or a vascular anomaly.

HEENT

Evaluate for nasopharyngeal source of bleeding.

Evaluate the buccal mucosa for syndromic findings: freckles (Peutz-Jeghers syndrome) and telangiectasias (Osler-Weber-Rendu syndrome).

Diagnostic Tests & Interpretation

NG tube lavage

No longer recommended in patients with suspected UGIB for diagnosis, prognosis, visualization, or therapeutic effect

Gastroccult test for blood

If possible, confirm red substances are blood.

In neonates, may need to check for fetal hemoglobin with the Apt test, which identifies fetal hemoglobin versus swallowed maternal blood.

CBC

Initial hemoglobin values may be unreliable because a time delay between blood loss and hemodilution may occur and falsely produce near-normal values. Therefore, hemoglobin should be measured serially.

If leukopenia or thrombocytopenia is present, consider chronic liver disease and portal hypertension.

If anemia is present with normal erythrocyte indices, there is truly an acute cause for bleeding. If erythrocyte indices indicate iron deficiency anemia, consider varices or a mucosal lesion (i.e., chronic blood loss).

Coagulation profile

If PT or PTT is abnormal, consider liver disease or disseminated intravascular coagulation (DIC) with sepsis.

If DIC screen is negative, consider liver disease. Important to avoid contamination of blood sample with heparin.

Liver function test results may be abnormal in chronic liver disease.

Imaging

Barium tests

Not useful in the acute setting

Barium can obscure view when performing esophagogastroduodenoscopy (EGD).

Abdominal x-ray

If small bowel obstruction or foreign body is suspected

Ultrasound

If portal hypertension is suspected

Bleeding scan

Useful in the patient with significant bleeding that precludes endoscopy or in whom endoscopy is nondiagnostic

Technetium-99m " Гґtagged erythrocyte scan detects rapid bleeding at a rate of 0.1 " Гґ0.5 mL/min. Can be performed at 30-minute intervals for up to 24 hours

Meckel scan: Technetium-99m pertechnetate-tagged can detect a Meckel diverticulum that contains gastric mucosa.

Angiography

Requires bleeding rate of 0.5 " Гґ1 mL/min to detect location. Useful in detecting vascular causes of upper GI bleeding

Can also be therapeutic (i.e., injection of coils into a vascular malformation)

Upper endoscopy

Upper endoscopy is the prime diagnostic and therapeutic tool for evaluating UGIB in pediatric patients.

90 " Гґ95% sensitive at locating bleeding site

Treatment

General Measures

Initial management:

Make patient NPO.

Obtain stable IV access.

Blood type and cross-match for PRBCs should be obtained.

Stabilize the patient with IV fluids and blood products as necessary (target hemoglobin ≥7 g/dL).

Target INR <2.5

Disease-specific therapy:

Peptic ulcer disease (medical therapy)

Proton pump inhibitors

H2 blockers

Sucralfate

Prokinetic agents

H. pylori eradication

Peptic ulcer disease (endoscopic therapy)

Hemoclip

Thermal therapy (i.e., bipolar vs. argon plasma coagulation)

Injection therapy (i.e., 1:10,000 epinephrine)

Esophageal varices:

Octreotide infusion

Esophageal band ligation

Sclerotherapy

Sengstaken-Blakemore tube

Portosystemic shunts

Issues for Referral

Immediate referral if bleeding is profuse, if patient is hemodynamically unstable, or if bleeding will not stop

Refer any patient with evidence of chronic iron deficiency anemia and heme-positive stools.

Surgery/Other Procedures

Patients with significant UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters.

If rebleeding occurs after endoscopy or if endoscopy is unable to achieve initial hemostasis, then surgery or angiography should be considered.

Ongoing Care

Monitor hemoglobin in the hospital until patient 's condition is stable.

If bleeding has stopped, endoscopy should still be strongly considered to determine source of bleeding.

Once patient is discharged, monitor patient 's hemoglobin and stool for occult blood weekly until stable.

More specific follow-up depends on the underlying condition.

A: You should refer patients immediately if there is evidence of significant and/or active bleeding, and or the patient is hemodynamically unstable. Patients with evidence of chronic iron deficiency anemia and heme-positive stools should be referred for elective, but timely evaluation.