Upper GI Bleed

Upper Gastrointestinal Bleeding

Definition

Bleeding from a GI site proximal to the ligament of Treitz

Background

5% of all pediatric esophagoscopies are indicated due to UGI Bleed
increased incidence in critically ill patient, <1% are life-threatening
Etiology based on Age: (PUD most common cause of UGI bleed in children)

Neonate

swallowed maternal blood
hemorrhagic disease of newborn
stress gastritis
peptic ulcer disease (PUD)
vascular anomaly
coagulopathy
milk protein sensitivity

Infants

stress gastritis
peptic ulcer disease (PUD)
Mallory-Weiss tear
vascular anomaly
gastrointestinal duplications
esophageal/gastric varicies
foreign body
hereditary telangiectasia

Child /Adolescent

Mallory-Weiss tear
esophagitis/gastritis
peptic ulcer disease (PUD)
varicies
caustic ingestion
vasculitis (HSP)
Crohn Disease
hemobilia
foreign body
tumor
telangiectasia

Clinical Manifestations

Presentation includes 3 options: Hematemesis, Coffee ground emesis, and Melena

Hematemesis

vomiting bright red blood
usually indicating a large volume rapid bleeding lesion

Coffee-ground emesis

blood denatured by contact with gastric acid

Melena

black, tarry stool
caused by bacterial oxidation of blood anywhere in the GI tract proximal to colon
can occur with as little as 50-100mL of UGI blood

Diagnosis

Evaluate patient

vitals, CV stability, LOC, Pallor, diaphoresis, restlessness, lethargy, abd pain
orthostatic changes when moving from supine to sitting - suggest rapid blood loss

increased HR by 20bpm
decrease in SBP >10mmHg

H&P - looking for conditions suggestive of etiology

hyperactive bowel sounds, borborygmi - UGI Bleed
petechiae, purpura - coagulopathy, thrombocytopenia, intense vomiting, HSP
hemangioma, telangiectasia - Vascular

caput medusae, spider angioma, jaundice - chronic liver disease
epistaxis - nose bleed
blood in hypopharynx - adenoid or tonsil disorder
hyperpigmented lesions in gums and lips - Peutz-Jeghers syndrome

Labs

CBC w/ diff
Retic count
coagulation panel (PT, PTT, INR)
Chemistry panel
LFTs
Blood type and crossmatch

NG Tube placed with irrigation

aspiration of blood (BRB or coffee ground) confirms bleeding location proximal to pylorus

Imaging - based on DDx

Plain films - if FB, Free air, or perforation suspected
UGI Contrast study - ulceration, radiolucent FB, duplication cysts

Abd US - portal blood flow - if Portal HTN suspected
Nuclear medicine - radiolabeled RBC scan - detect active bleeding source to a flow as low as 0.1mL/min
Angiography - can detect flow at 0.5mL/min or higher

can also coil/embolize bleeding vessel

Endoscopy

Test of choice
Identifies mucosal lesions and source of bleed in ~90% of cases
contraindicated in unstable or severely anemic patients

Treatment

PALS - as needed to correct shock, fluid loss
correct anemia
correct coagulopathy and metabolic/electrolyte abnormality
Pharmacologic therapy

PPI IV/PO for Acid suppression
Sucralfate

40-80mg/kg/day div in 2-4 doses
binds to base of ulcer allowing lesion to heal

Variceal Bleed

Octreotide

1-2 mcg/kg IV bolus followed by 1-4mcg/kg/hr continous infusion
reduced splanchnic and portal blood flow
may be used in nonvariceal bleeds
when bleeding controlled, reduce dose by 50% over 12hrs
discontinue when dose is 25% of starting dose

Active bleed seen on endoscopy

Epinephrine 1:10000 in NS, injected into or near any oozing lesion
contact thermal methods, hemostasis through local tamponade, coagulation, blood vessel wall fusion
endoscopic clip placement

Variceal Bleeding

Esophageal varicies form in adults with portal HTN and hepatic venous pressure gradient >10mmHg
Risk for bleeding when pressure exceeds 12mmHg
Etiology

Uphill

Hypertension will spontaneously decompress through the portosystemic collateral circulation via the coronary vein along with L gastric veins which produces esophageal varicies

Downhill

In the absense of portal HTN, SVC obstruction can produce esophageal varicies as well

Causes of pediatric Portal HTN, biliary atresia, extrahepatic portal vein obstruction are unique from diseases in adults
typically children have well compensated liver disease and tolerate variceal bleeds better
mortality risk <1% after initial bleed

Presentation

significant hematemesis and melena

most will present with liver disease, some with extrahepatic portal venous obstruction will be otherwise asymptomatic

Any peds patient presenting with hematemesis and splenomegaly should be presumed to have variceal bleeding until proved otherwise

Endoscopy - preferred Dx test

can identify risk for bleeding - predictors of bleeding include:

large varicies
red marks
presence of gastric varicies

enable therapy - sclerotherapy or band ligation

Prophylaxis - goal to prevent initial hemorrhage and reduce risk of esophageal bleed

nonselective beta-blockade (e.g. propranolol or nadolol)
sclerotherapy
ligation
portosystemic shunt surgery
recent expert concensus on large review propose MesoRex bypass surgery for children with EHPVO as both primary and secondary prophylaxis ****

insufficient evidence to offer endoscopic therapy and beta-blockade as primary prophylaxis in children - evidence for benefit seen in adults compared to control

Management of Acute variceal bleeding

obtain hemodynamic stability:

tranfusion
vasoactive drugs (octreotide)
short term Abx
Endoscopy - ligation or sclerotherapy
Transjugular intrahepatic portosystemic shunt should be considered for variceal bleeding refractory to endoscopic or medical therapy

Prophylaxis (secondary)

randomized controlled trial has shown superiority of ligation over sclerotherapy in reducing the risk of rebleeding and complications

References:

Kliegman, Robert. Nelson Textbook of Pediatrics. Edition 21. Philadelphia, PA: Elsevier, 2020.
Tortora, Gerard J. Principles of Anatomy and Physiology. 15th ed. Hoboken, NJ: J. Wiley, 2009. Print.
Moore, Keith L.,, Arthur F. Dalley, II, and Keith L Moore. Clinically Oriented Anatomy. Fifth edition. Baltimore: Wolters Kluwer Health, 2009. Print.
Kleinman RE, Goulet O, Mieli-Vergani G, et al, eds. Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, and Management. 5th ed. Hamilton, Ontario: BC Decker; 2008.
The NASPGHAN fellows concise review of pediatric gastroenterology, hepatology, and nutrition. 1st edition (2011)
Wyllie, Robert & Hyams, J.S.. (2011). Pediatric Gastrointestinal and Liver Disease. 10.1016/C2009-0-53242-4. (Accessed online Feb 2020)
Coran, Arnold G, and N S. Adzick. Pediatric Surgery. Philadelphia, PA: Elsevier Mosby, 2012. Internet resource.
****Shneuder BL etal, Primary prophylaxis of variceal bleeding in children...Hepatology 2016;63:pp1368-1380