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 " Ł 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 " ô5 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 " öcoagulopathy, Henoch-Sch â Ânlein 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 " ôtagged erythrocyte scan detects rapid bleeding at a rate of 0.1 " ô0.5 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 " ô1 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 " ô95% 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.
Additional Reading
Chawla é áS, Seth é áD, Mahajan é áP, et al. Upper gastrointestinal bleeding in children. Clin Pediatr. 2007;46(1):16 " ô21. é á[View Abstract]
Kato é áS, Sherman é áP. What is new related to Helicobacter pylori infection in children and teenager? Arch Pediatric Adolsc Med. 2005;159(5):415 " ô421. é á[View Abstract]
Kim é áSJ, Kim é áKM. Recent trends in the endoscopic management of variceal bleeding in children. Pediatr Gastroenterol Hepatol Nutr. 2013;16(1):1 " ô9. é á[View Abstract]
Pai é áN, Manfredi é áMA. Endoscopic management of gastrointestinal bleeding in pediatrics. Tech Gastrointest Endosc. 2013;15(1):18 " ô24.
Uppal é áK, Tubbs é áRS, Matusz é áP, et al. Meckel 's diverticulum: a review. Clin Anat. 2011;24(4):416 " ô422.
Codes
ICD09
578.9 Hemorrhage of gastrointestinal tract, unspecified
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.