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

• 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)

• 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

• Balloon tamponade: Blakemore tube can be placed in esophagus (do not use longer than 12hrs in kids)

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