Overview
Definition:
Upper gastrointestinal (GI) bleeding in children refers to bleeding originating from the esophagus, stomach, or duodenum
It can manifest as hematemesis (vomiting blood) or melena (dark, tarry stools).
Epidemiology:
The incidence of upper GI bleeding in children is relatively low compared to adults, with estimates varying widely
Common causes include esophagitis, gastritis, peptic ulcers, and more rarely, variceal bleeding
Non-variceal causes are more frequent in younger children, while variceal bleeding is associated with underlying liver disease.
Clinical Significance:
Upper GI bleeding in children can be a life-threatening emergency requiring prompt recognition and management
Understanding the differential diagnosis, particularly the distinction between variceal and non-variceal causes, is crucial for appropriate treatment strategies and improved patient outcomes.
Clinical Presentation
Symptoms:
Hematemesis, often described as bright red or coffee-ground material
Melena, which is dark, tarry, and foul-smelling stool
Abdominal pain or discomfort
Dysphagia or odynophagia
Vomiting
Pallor, weakness, or dizziness if significant blood loss has occurred.
Signs:
Vital sign abnormalities such as tachycardia, hypotension, and tachypnea (indicating hypovolemic shock)
Abdominal tenderness or distension
Palpable hepatosplenomegaly (suggestive of portal hypertension and varices)
Signs of anemia (pallor, jaundice)
Rectal examination may reveal melena or fresh blood.
Diagnostic Criteria:
Diagnosis is primarily clinical, confirmed by the presence of hematemesis or melena
Further investigations are guided by the clinical suspicion of the underlying etiology
Hemodynamic stability is the immediate priority for management.
Diagnostic Approach
History Taking:
Detailed history of vomiting, blood in vomitus or stool
Duration and quantity of bleeding
Associated abdominal pain
History of prematurity, birth trauma, or prolonged intubation (risk for stress ulcers)
Family history of bleeding disorders or GI issues
Medications (NSAIDs, steroids, anticoagulants)
History of liver disease, jaundice, or portal hypertension
Recent infections (e.g., H
pylori).
Physical Examination:
Assess for signs of shock (hypotension, tachycardia)
Examine for pallor, jaundice, and signs of chronic liver disease (ascites, spider angiomata, palmar erythema)
Palpate for hepatosplenomegaly
Perform a digital rectal examination to assess for melena or occult blood.
Investigations:
Complete Blood Count (CBC) to assess for anemia and platelet count
Coagulation profile (PT, aPTT, INR) to evaluate hemostasis
Liver function tests (LFTs) to assess hepatic synthetic function and presence of liver disease
Blood typing and crossmatching for potential transfusion
Urea and electrolytes to assess hydration status
Stool for occult blood
If variceal bleeding is suspected: Abdominal ultrasound to evaluate for signs of portal hypertension (splenomegaly, ascites, portal vein diameter)
Esophagogastroduodenoscopy (EGD) is the gold standard for diagnosis and can be therapeutic
Upper GI series may be useful in select cases to identify structural lesions but is less sensitive for varices.
Differential Diagnosis:
Variceal bleeding (e.g., from esophageal or gastric varices secondary to portal hypertension)
Non-variceal causes include: Esophagitis (infectious, reflux, eosinophilic)
Gastritis or duodenitis (NSAID-induced, stress-related, H
pylori)
Peptic ulcer disease
Mallory-Weiss tears
Esophageal or gastric polyps
Duodenal duplication cysts
Vascular malformations
Gastric antral vascular ectasia (GAVE).
Management
Initial Management:
Establish intravenous access with at least one large-bore catheter
Aggressive fluid resuscitation with crystalloids (e.g., normal saline, Ringer's lactate) to maintain hemodynamic stability
Monitor vital signs closely, including heart rate, blood pressure, and oxygen saturation
Administer oxygen if hypoxemic
Obtain blood for CBC, coagulation studies, and crossmatch
Correct coagulopathy with fresh frozen plasma (FFP) or platelet transfusion as needed.
Medical Management:
Proton pump inhibitors (PPIs) are crucial for all significant upper GI bleeds to reduce gastric acidity and promote healing (e.g., Pantoprazole 1-2 mg/kg/day IV in divided doses or as continuous infusion)
For suspected variceal bleeding, octreotide (intravenous infusion, typically 1-2 mcg/kg/hr after a bolus of 1 mcg/kg) may be used to reduce splanchnic blood flow and portal pressure
Antibiotics are indicated in patients with variceal bleeding to prevent spontaneous bacterial peritonitis (e.g., Ceftriaxone or Ciprofloxacin)
H
pylori eradication therapy if confirmed.
Endoscopic Management:
Esophagogastroduodenoscopy (EGD) is the cornerstone of diagnosis and management for both variceal and non-variceal bleeding
Variceal bleeding: Band ligation or sclerotherapy of varices
Non-variceal bleeding: Endoscopic hemostasis with epinephrine injection, thermal coagulation (e.g., bipolar electrocoagulation, heater probe), or mechanical clipping
For actively bleeding ulcers or visible non-variceal lesions, combination therapy (e.g., injection + clipping/coagulation) is often employed.
Surgical Management:
Surgical intervention is rarely required but may be considered for severe, life-threatening bleeding that is refractory to endoscopic management
Options include gastric resection, ligation of bleeding vessels, or portasystemic shunting procedures (rare in children).
Supportive Care:
Continuous monitoring of vital signs and urine output
Strict intake and output charting
Nasogastric tube insertion for gastric decompression and lavage (though its routine use for bleeding control is debated)
Transfusion of packed red blood cells (PRBCs) to maintain adequate hemoglobin levels (target generally > 7-9 g/dL, higher in active bleeding or significant comorbidities)
Nutritional support, especially if prolonged NPO status is anticipated.
Complications
Early Complications:
Hypovolemic shock
Anemia
Rebleeding
Aspiration pneumonia
Electrolyte imbalances
Acute kidney injury.
Late Complications:
Chronic anemia
Malnutrition
Liver decompensation (in patients with underlying liver disease)
Formation of gastric or esophageal strictures post-endoscopic therapy
Portal hypertensive gastropathy/colopathy.
Prevention Strategies:
Prompt and aggressive management of shock
Early identification and treatment of the underlying cause
Judicious use of PPIs
Careful endoscopic technique
Prophylactic antibiotics in variceal bleeding
Avoidance of NSAIDs in high-risk patients.
Prognosis
Factors Affecting Prognosis:
The severity of bleeding
Hemodynamic stability
The underlying etiology (variceal vs
non-variceal)
Presence of comorbid conditions, particularly liver disease
Promptness and efficacy of treatment
Age of the child (neonates and infants have higher risks).
Outcomes:
With prompt and appropriate management, the prognosis for most children with upper GI bleeding is good
Mortality is generally low, but can be significant in cases of severe shock, massive rebleeding, or severe underlying liver disease
Patients with variceal bleeding often require long-term management for portal hypertension.
Follow Up:
Follow-up depends on the etiology
Patients with peptic ulcers or gastritis may require follow-up EGD to confirm healing and H
pylori eradication
Patients with varices require lifelong monitoring for rebleeding and surveillance for hepatocellular carcinoma (if underlying cirrhosis)
Regular LFT monitoring is essential for children with liver disease.
Key Points
Exam Focus:
Differentiate causes of pediatric upper GI bleed: variceal (often from portal hypertension) vs
non-variceal (ulcers, esophagitis, gastritis)
Key investigations: CBC, Coags, LFTs, EGD
Management staples: IV fluids, PPIs, endoscopy
Octreotide for variceal bleed
Antibiotics for variceal bleed prevention.
Clinical Pearls:
Always assess hemodynamic stability first in a child with suspected GI bleed
Coffee-ground vomitus suggests an older bleed or slower bleed into the stomach
Melena indicates bleeding in the upper GI tract, taking time to transit
Consider NSAID use and H
pylori in non-variceal etiologies.
Common Mistakes:
Delaying resuscitation in unstable patients
Not considering variceal bleeding in children with hepatosplenomegaly or known liver disease
Inadequate acid suppression with PPIs
Failure to consider endoscopic intervention for active bleeding
Inappropriate antibiotic use or omission in variceal bleed.