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Gastrointestinal Hemorrhage

Carolyn A. Sullivan, MD Pediatric Gastroenterology

Walter Reed Army Medical Center

Objectives Describe

the diagnostic and therapeutic approach to the pediatric patient with GI bleeding Review the most common etiologies for GI bleeding in pediatric patients in various age groups

Definitions Melena:

passage of black, tarry stools; suggests bleeding proximal to the ileocecal valve Hematochezia: passage of bright or dark red blood per rectum; indicates colonic source or massive upper GI bleeding Hematemesis: passage of vomited material that is black (coffee grounds) or contains frank blood; bleeding from above the ligament of Treitz

HistoryPresent illness source, magnitude, duration of bleeding associated GI symptoms (vomiting, diarrhea, pain) associated systemic symptoms (fever, rash, joint pains) Review of systems GI disorders, liver disease, bleeding diatheses Anesthesia reactions medications (NSAIDs, warfarin)

Physical examination Vital

signs, including orthostatics Skin: pallor, jaundice, ecchymoses, abnormal blood vessels, hydration, cap refill HEENT: nasopharyngeal injection, oozing; tonsillar enlargement, bleeding Abdomen: organomegaly, tenderness, ascites, caput medusa Perineum: fissure, fistula, induration

Further assessment Is

it really blood?Hemoccult stool, gastroccult emesis


test in neonates Nasogastric aspiration and lavage

Clear lavage makes bleeding proximal to ligament of Treitz unlikely Coffee grounds that clear suggest bleeding stopped Coffee grounds and fresh blood mean an active upper GI tract source

Substances that deceive Red


candy, fruit punch, Jell-o, beets, watermelon, laxatives, phenytoin, rifampin



bismuth, activated charcoal, iron, spinach, blueberries, licorice

Laboratory studies CBC,

ESR; BUN, Cr; PT, PTT in all cases Others as indicated:

Type and crossmatch AST, ALT, GGTP, bilirubin Albumin, total protein Stool for culture, ova and parasite examination, Clostridium difficile toxin assay

Imaging studies and indications Upper

GI series: dysphagia, odynophagia, drooling Barium enema: intussusception, stricture Abdominal US: portal hypertension Meckels scan: Meckels diverticulum Sulfur colloid scan, labeled RBC scan, angiography : obscure GI bleeding

Endoscopy: indications EGD:

hematemesis, melena Flexible sigmoidoscopy: hematochezia Colonoscopy: hematochezia Enteroscopy: obscure GI blood loss

DDx: neonates

Upper GI bleeding

Lower GI bleeding

swallowed maternal blood stress ulcers, gastritis duplication cyst vascular malformations vitamin K deficiency hemophilia maternal ITP maternal NSAID use

swallowed maternal blood dietary protein intolerance infectious colitis necrotizing enterocolitis Hirschsprungs enterocolitis duplication cyst coagulopathy

Neonatal stress ulcers or gastritis Causes

Shock Sepsis Dehydration Traumatic delivery Severe respiratory distress Hypoglycemia Cardiac condition

DDx: infants

Hematemesis, melena


Esophagitis Gastritis Duodenitis

Anal fissures Intussusception Infectious colitis Dietary protein intol. Meckels diverticulum Duplication cyst Vascular malformation

DDx: children

Upper GI bleeding

Lower GI bleeding

Esophagitis Gastritis Peptic ulcer disease Mallory-Weiss tears Esophageal varices Pill ulcers

Anal fissures Infectious colitis Polyps Lymphoid nodular hyperplasia IBD HSP Intussusception Meckels diverticulum HUS

Esophageal varices

Erosive esophagitis

DDx: adolescents

Hematemesis, melena


Esophagitis Gastritis Peptic ulcer disease Mallory-Weiss tears Esophageal varices Pill ulcers

Infectious colitis Inflammatory bowel disease Anal fissures Polyps

NSAID induced ulcers

Peptic Ulcer

Mallory-Weiss Tear

Risk of rebleeding of ulcer

Stigmata of recent hemorrhage

Rate of rebleed

Visible vessel Clot Spot Clean base

40-50% 25-30% 10% 2-4%

Ulcer with red spot


Supportive care: begin promptly IV fluids, blood products, pressors Specific care Barrier agents (sucralfate) H2 receptor antagonists (cimetidine, ranitidine, etc.) Proton pump inhibitors (omeprazole, lansoprazole) Vasoconstrictors (somatostatin analogue, vasopressin) Endoscopic therapy: stabilize and prepare patient first Coagulation (injection, cautery, heater probe,

Bleeding Ulcer