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
ManagementGeneral- 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)
- Octreotide: Reduces 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
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
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 146236222) J.B. Heikenen, J.F. Pohl, S.L. Werlin, et al.: Octreotide in pediatric patients. J Pediatr Gastroenterol Nutr. 35:600-609 2002 124545723) 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 95238764) A. Zellos, K.B. Schwarz: Efficacy of octreotide in children with chronic gastrointestinal bleeding. J Pediatr Gastroenterol Nutr.30:442-446 2000 107769595) J.P. Molleston: Variceal bleeding in children. J Pediatr Gastroenterol Nutr. 37:538-545 2003 14581793 |