Approach to a child with hematemesis or melena

Avijeet k. Mishra

1st year Resident

Guide – Dr Surya Bahadur Thapa

DOCH

Contents Introduction

Etiology

Initial assessment and stabilization

History

Physical examination

Investigations

Management

summary

Case

A 32 months old male presented to us with a history of 2 days of abdominal pain , 3 episodes of black colored stool and 1 episode of fresh blood mixed with feces small in quantity without any similar past history. He had uneventful neonatal period and no history of rashes or bleeding from other sites.

Introduction

Upper gastrointestinal bleeding-

Bleeding from a site proximal to the ligament of Treitz

Hematemesis is the cardinal sign

Some may present with melena

Lower gastrointestinal bleed-

Bleeding from site distal to the ligament of Treitz

Hematochezia is the usual presentation

Contd.. Hematemesis-

Vomiting of blood which may be red or coffee grounds

Melena-

Passage of black tarry stools

Action of digestive enzymes and bacteria change the color of stool to

black tarry and foul smelling

Hematochezia –

Passage of fresh blood per anus, usually in or with stool

Etiology

Neonate Swallowed maternal blood

- During delivery

- From mother’s nipple

Coagulopathy

- Hemorrhagic disease of the newborn

- Septicemia, DIC

- Hemophilia

Contd…

Stress ulcers/ gastritis – critically ill newborns

Drug intake

-by mother: warfarin, aspirin

-by neonate: indomethacin, steroids

Vascular malformation- hemangioma, AV-malformation

Duplication cyst

Gastrointestinal polyposis syndrome

Contd…..

Infant Mucosal erosion :

-Reflux esophagitis

-Pyloric stenosis

Coagulation disorders

Bacterial/amoebic enteritis, Intussusception, Mid gut volvulus,

Meckel's diverticulum, Milk protein allergy, AV malformation

Contd..Children Swallowed epistaxis

Reflux esophagitis

Gastric erosion/ gastritis/ peptic ulcer

Esophageal varices

Mallory-Weiss syndrome

Coagulopathy

Dysentery, intussusception, volvulus, Meckel’s diverticulum, colonic polyps, HSP

Contd..

Adolescents Swallowed epistaxis

Gastric erosion/ gastritis/ peptic ulcer (drugs, H. pylori infection, stress-

severe systemic disease, burn, raised ICP)

Mallory Weiss tear

Esophageal varices

Inflammatory bowel disease, dysentery, colonic polyps

Vascular lesions- telangeictasia, angiodysplasia, hemangioma,

AV malformation

Contd….

At our center out of 83 patients with gastrointestinal bleeds

undergoing endoscopy, 40 were found to have esophageal

varices, 8 had gastric erosion , 1 had polyp and 34 had

normal endoscopy

Initial assessment and stabilization

As for any other emergency the first priority should be to assess the circulation, breathing and airway of a patient presenting with UGIB

Most important aspect of evaluation is to determine the degree and rapidity of blood loss

Orthostatic changes in BP(more than 10 mm Hg) suggest a moderate bleed(15-20% blood loss) and warrant a more aggressive approach to management

Presence of signs of shock (tachycardia, prolonged CRT, cold clammy skin, supine hypotension) indicates severe bleed of more than 25-30% of blood loss and a need for immediate volume expansion and stabilization before proceeding to a diagnostic algorithm

contd..

1. Whether actual blood loss or ingested substances

• Hematemesis

food coloring

red candy

colored gelatin

beets

tomato skin

rifampin

phenytoin

• Melena

bismuth

iron preparations

licorice

spinach

grapes

blueberries

charcoal

Contd…- For detecting blood in vomitus or nasogastric aspirate Gastroccult test is used

2. In neonate –Whether patients own blood or swallowed blood

Apt-Downey test is used to differentiate

Contd…3. Is there a pulmonary, oral or ENT source of bleed?

- Epistaxis, sore throat, dental procedures or tonsillectomy

- Hence these areas must be explored to rule out in cases of doubt

4. Level of bleeding- Acute onset hematochezia or melena- level of bleeding can be

confirmed by the passage of a nasogastric tube

- Presence of blood in stomach and clearing of nasogastric aspirate with

lavage are diagnostic of UGIB

Focused history

Age of patient

Magnitude and duration

Color and amount of hematemesis/ melenous stool

Associated GI symptoms :- vomiting, diarrhea, pain

Associated systemic symptoms :- fever, rash, joint pains, dizziness, palpitations

Contd.. Sudden onset of bright color hematemesis and melena

of large amount: Esophageal varices

Gradual onset chronic, mild hematemesis and melena: Acid peptic disease

Preceding repeated forceful vomiting and retching: Mallory Weiss syndrome

Contd..

Acid regurgitation, nausea, vomiting, water brash, retrosternal pain: Reflux esophagitis

Anorexia, nausea, vomiting and epigastric pain with relation to food: Peptic ulcer

Bloody diarrhea, vomiting, abdominal pain, fever: Dysentery

History of easy bruising or bleeding: coagulation, platelet dysfunction or thrombocytopenia

Contd.. History of drug intake: NSAIDS, corticosteroids, Mucosal irritants, iron

preparation: Gastritis.

Poisoning : Paracetamol, iron.

Risk factors for portal HTN: umbilical sepsis / catheterization, jaundice, liver disease- Esophageal varices

H/o chronic cough, recurrent lung infections: Cystic fibrosis, Bronchiectasis.

Contd… Review of Systems

GI disorders

Liver disease

Bleeding diathesis

Family History

GI disorders (polyps, ulcers, colitis)

Liver disease

Bleeding diathesis

Physical examination

Vital signs :- PR, BP, RR, CRT

Pallor, diaphoresis, confusion, obtundation, tachycardia, tachypnea → Shock.

Acute losses of 10-25% of blood volume cause tachycardia, narrow pulse pressure and postural hypotension.

Earliest sign to increase is HR

Contd..

Pallor- Increased paleness will point towards ongoing blood loss

Icterus- chronic liver disease

Skin- petechiae, Purpura, ecchymoses, vascular malformations, stigmata for chronic liver disease like spider angioma, palmar erythema

Examination of nose, oral cavity and throat

Contd…..

Gastrointestinal examination

1. Epigastric tenderness – acute gastritis or peptic ulcer disease

2. Protruding abdomen, prominent blood vessels and

Hepatosplenomegaly – portal hypertension and bleeding

from esophageal varices

3. Splenomegaly- Extrahepatic portal vein obstruction(EHPVO)

4. Examination of perineum and rectum

Investigations In an emergency setting only a few tests are essential in the beginning to

evaluate UGIB

CBC

PT/INR

APTT

LFT

Blood grouping and Cross matching

Further investigations

1. abdominal USG- EHPVO, portal hypertension due to liver disease, large vessel anomalies, splenic artery aneurysm

Contd..2. Endoscopy-

- UGI endoscopy is the gold standard for diagnosis and treatment of UGIB

- Procedure of choice for all patients with UGIB.

- In the skilled hands diagnosis of etiology in 85-90% of cases

- Contraindicated in in hemodynamically unstable patients

3. CT angiography- Vascular malformations beyond the duodenum , in areas not

accessed by routine UGI endoscopy

Contd..4. Nuclear scintigraphy-

- In persistent bleeding in whom endoscopy fail

- Useful only if the rate of bleeding exceeds 0.1 ml/min

5. Angiography-

- Celiac/ superior mesenteric artery angiography is used selectively in children with

non-variceal bleeding eg from peptic ulcer, that obscures endoscopic evaluation and

therapy

- Also important in hemobilia, splenic artery aneurysm and some types of vascular

malformation

- Bleeding must be 0.5 ml/min to be detected by angiography

Management The initial steps in the management of severe UGIB include assessment,

resuscitation, re- evaluation, identification of the cause and source of bleeding and commencing appropriate treatment

Resuscitation and stabilization

1. Circulation-

large bore venous access to restore blood volume

crystalloids initially

blood transfusion

Contd….Blood transfusion-

- Rate depends on severity, continuing active bleeding and co-morbidities

- BT not needed in hemodynamically stable patient that has hematocrit above 24%

- Overtansfusion should be avoided in variceal bleed

2. Airway –

-Intubation in uncontrolled massive hematemesis to prevent aspiration and

facilitate endoscopy if necessary

3. Breathing – Supplemental oxygen

Contd..Reassessment and monitoring-

-Vitals should be monitor every 10- 15 minutes till stabilized

-Then hourly for 24 hours after bleeding stops

Nasogastric aspiration-Aspiration and saline lavage indicated in all patients with UGIB to confirm

- Presence of intragastric blood

- Rate of gross bleeding

- Check for ongoing or recurrent bleeding

- Clear gastric field for endoscopic visualization

- Prevent aspiration

- Prevent hepatic encephalopathy in patients of cirrhosis

Contd…Correction of coagulopathies-

- Vitamin k given empirically

- Coagulopathy with INR >1.5 or abnormal aPTT- FFP

Pharmacotherapy1. Variceal bleed-

Octeotride- Drug of choice for variceal bleed

Acts by decreasing splanchnic blood flow

Vasopressin, Terlipressin

Somatostatin

2. Prokinetic agents- Erythromycin, Metoclopramide

3. Mucosal bleed- PPI, H2 blocker

Contd…. Endoscopic techniques

1. Variceal bleed-

Endoscopic sclerotherapy is the mainstay of treatment in this group

Endoscopic variceal ligation

2. Nonvariceal bleed

Injection adrenaline and saline

Endoclip devices

Balloon tamponade

Sengstaken-blakemore tube

Used in whom bleeding continues despite pharmacotherapy and endoscopic

methods

Case

Our case presented to us in the ER. At presentation he was an average build child with pallor and vitals of T-98*F, PR- 170, BP-90/60, RR- 36. He was pale and anicteric. On per abdomen he had splenomegaly of about 3 cm. Rest of the exam was normal.

Lab investigations-

Hb- 5.7, TLC – 13,000, platelets 17,600

LFT-N , RFT- N

PT/INR- N, aPTT- N

Contd…

USG abdomen- splenomegaly, N hepatic echotexture, thickened wall of extrahepatic portal vein

CT portogram- portal cavernoma with multiple collaterals at splenic hilum, peri-cholecystic, peri-pancreatic region

UGI endoscopy- grade 3 varices

Summary

UGI bleeding is a potentially life threatening emergency requiring an appropriate diagnostic and therapeutic approach

Therefore primary focus in a child with UGI bleed is resuscitation and stabilization followed by a diagnostic evaluation

In infants and toddlers mucosal erosion is the most common cause while in older children variceal bleeding due to EHPVO is most common

UGI endoscopy is the most accurate and useful diagnostic tool to evaluate UGI bleed

Treatment depends on the cause

Reference

Indian journal of pediatrics

Pediatric in review

Nelson textbook of pediatrics

www.Wikipedia.com