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GI Bleed

Definitions

  • UGIB: bleeding proximal to the ligament of Treitz
  • Hematemesis, melena, and even hematochezia seen
Etiology
  • Esophageal varices (EV) one of the most common causes in children
Figure 1: Example of esophageal varices before and after banding
  • Esophagitis, gastritis, ulcers, and "unknown"
  • Less common are Dieulafoy's, AVM, Mallory Weiss, tumors, IBD, vasculitis (HSP)

Initial assessment

  • Hemodynamics (Orthostatic BP if able, cap refill, etc.)
  • Is it truly blood? Can use Gastroccult test to see if it becomes positive for blood (do not use Hemoccult test...the pH of gastric fluid leads to false results)
  • Is it GI vs pulmonary, oral, or ENT source? Assess for sore throat, epistaxis, cough, etc
  • Is it truly "upper" GI bleed? Use NG lavage to determine if blood coming from stomach and/or above
Labs
  • CBC, coags, LFTs, T/S, consider H. pylori testing if indicated
Imaging
  • Abd U/S w/ doppler if clinically indicated
  • Endoscopy for diagnostic and therapeutic measures
  • Consider angiography with IR for both diagnostic and therapeutic (ie embolization) purposes
  • Consider tagged red blood cell scan

Management

General
  • ABC's
  • Make sure to have at least 2 large bore IVs
  • NG lavage (Indicated in all pts, but if pt has a h/o esophageal banding, should discuss with the GI team
  • Ice water for its vasoconstrictive effect, but evidence is lacking
  • Correct coagulopathies and severe thrombocytopenia
  • Transfusion therapy is unclear as to what Hb target one should transfuse for. Clearly with massive bleeding, transfusions are indicated. However, in the adult population, Villanueva et al found that a restrictive transfusion strategy with a threshold of 7 vs 9 g/dl, survival and the risk of rebleeding was actually improved with the restrictive strategy (Villanueva et al, NEJM 2013). This is for severe but not massive UGI bleed. 
  • May require massive transfusion protocol
    • 1:1:1 ratio of PRBC: FFP: Plt (in units). This mimics whole blood and prevents coagulopathy or thrombocytopenia that would occur with transfusion of primarily PRBC's
    • Must be aware of hypocalcemia (due to citrate in blood products)
    • Monitor and treat hypothermia (cold blood products) as it contributes to coagulopathy
    • Monitor and treat hyperkalemia (due to blood products)
  • Some bleeds may stop with NPO/PPI infusion/+/- octreotide infusion/transfusion therapy as needed
  • Others may require endoscopic repair
  • Other options include interventional radiology for embolization of a bleeding artery
  • Surgery to identify and repair life threatening bleeding otherwise not seen via endoscopy or IR angiography
Variceal bleed
  • Meta-analysis comparing emergency sclerotherapy and pharmacotherapy shows similar efficacy with fewer side effects with the latter (so pharmacotherapy is 1st line therapy)
  • OctreotideReduces splanchnic blood flow, Controls UGIB in 70% of kids, Bolus 1mcg/kg followed by 1mcg/kg/hr titrated up to 4mcg/kg/hr, Infusions continued for 24-48hrs after the bleeding has stopped. Can cause hyperglycemia as a side effect
  • Vasopressin: As effective as octreotide, and its use has largely been replaced by octreotide
  • Endoscopic: Perform asap after initial stabilization, Variceal ligation, sclerotherapy, argon plasma coagulation
  • Balloon tamponade: Blakemore tube can be placed in esophagus (do not use longer than 12hrs in kids)
Figure2: Blakemore Tube

Mucosal bleed (ulcers)
  • PPI:<40kg --> 1mg/kg IV qday. >40kg --> 20-40mg IV qday, BID dosing also commonly used. Infusion also can be used, but no clear evidence that infusion is better than intermittent 
  • Endoscopic: Epi injection, clips, thermocoagulation


References

1) A. Barkun, M. Bardou, J.K. Marshall: Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 139:843-857 2003 14623622


2) J.B. Heikenen, J.F. Pohl, S.L. Werlin, et al.: Octreotide in pediatric patients. J Pediatr Gastroenterol Nutr. 35:600-609 2002 12454572


3) C. Siafakas, V.L. Fox, S. Nurko: Use of octreotide for the treatment of severe gastrointestinal bleeding in children. J Pediatr Gastroenterol Nutr. 26:356-359 1998 9523876


4) A. Zellos, K.B. Schwarz: Efficacy of octreotide in children with chronic gastrointestinal bleeding. J Pediatr Gastroenterol Nutr.30:442-446 2000 10776959


5) J.P. Molleston: Variceal bleeding in children. J Pediatr Gastroenterol Nutr. 37:538-545 2003 14581793