Description/Etiology
Gastrointestinal (GI) hemorrhage is bleeding from any site in the GI tract (i.e., esophagus, stomach, small intestine, colon). Most cases of GI bleeding occur in the upper GI tract; upper GI bleeding (UGIB) is defined as GI bleeding above the ligament of Treitz (i.e., ligament that suspends the duodenum). The clinical presentation of GI bleeding ranges from asymptomatic to hypovolemic shock. An active GI bleed in a child can progress rapidly to hypovolemia and shock. Severe GI bleeding is rare among the pediatric population and therefore, the documented research is limited(Wolfram et al.; 2013).
GI lesions (e.g., ulcers, varices) and mucosal irritation (e.g., esophagitis, gastroenteritis) are the most common causes of pediatric GI bleeding. Necrotizing enterocolitis and allergic colitis (e.g., cow’s milk protein allergy) are two common causes specific to children. Esophageal varices, gastritis, peptic ulcers, coagulopathy, and vascular malformations can all produce UGIB. Peptic ulcers can develop secondary to the stress of illness or from ingestion of some drugs (e.g., NSAIDs, steroids), caustic substances, or foreign bodies. Cancer is seldom the cause of pediatric GI bleeding.
Method of treatment depends on bleeding location and severity; I.V. fluids, blood transfusion, oxygen, close monitoring of vital signs, and other supportive measures can be warranted. Stomach contents are aspirated through a nasogastric tube to determine if the bleeding is in the upper or lower GI tract. Endoscopy is performed to locate and evaluate the source of bleeding. Therapeutic endoscopy can resolve bleeding with thermal or mechanical techniques, or by injection of a sclerosing agent; however, if endoscopic therapy fails or the bleeding site is unknown, surgery might be necessary. Pharmacotherapy can include H2-blockers (e.g., ranitidine, cimetidine), antacids, cytoprotective agents (e.g., sucralfate), hormones/hormone analogues (e.g., vasopressin, terlipressin, somatostatin, octreotide), and β-blockers (e.g., propranolol).
Facts and Figures
Ten percent to 20% of all referrals to pediatric gastroenterologists are for GI bleeding, and 6–20% of PICU patients have UGIB. Endoscopy identifies the bleeding source 90% of patients with UGIB if performed within 24 hours of onset, and colonoscopy identifies the bleeding source in 80% of patients with lower GI bleeding (LGIB).
Risk Factors
Gastritis increases risk for UGIB in children of all ages; other causes of GI bleeding vary according to age. Among infants, common causes include hemorrhagic disease secondary to vitamin K deficiency, anal fissure, and necrotizing enterocolitis. In older children, common causes include esophagitis, peptic ulcer disease, allergic colitis, juvenile polyps, Meckel diverticulum, rectal prolapse, and esophageal varices.
Signs and Symptoms/Clinical Presentation
Clinical presentation depends on the child’s age, etiology and location of bleeding, and whether bleeding is acute or chronic. Signs and symptoms (S/S) of acute GI bleeding can include hematemesis, melena (i.e., dark, tarry stools containing blood, indicating UGIB), hematochezia (i.e., bright red, bloody stools usually indicating LGIB), and tachycardia. Other S/S include diarrhea, abdominal tenderness or pain, anorexia, and irritability.
Assessment
Patient History
Ask about history of S/S (e.g., duration, progression, and type; jaundice; easy bruising; stool color changes)
Ask about recent travel, exposure to sick persons, and foods and drugs the child has taken, as some (e.g., fruit-flavored drinks, fruit juice, beets, licorice, bismuth subsalicylate [Pepto-Bismol], iron supplements) can mimic the appearance of bloody stool and/or hematemesis
Physical Findings of Particular Interest
Patient can have signs and symptoms of upper and lower GI bleeding, including tachycardia (blood loss); vomiting, epigastric pain, protruding abdomen, (Singhi et al; 2013)diarrhea, petechiae, echymoses and malformed blood vessels,(Singhi et al; 2013)and fever (infection); or an hepatomegaly, splenomegaly, or jaundice (liver disease)
Patients with UGIB may have melena, hematemesis, and hyperactive bowel sounds; hematochezia can be present if blood passes rapidly through the GI tract
Patients with LGIB can have bright red rectal blood; abdominal tenderness (intussusception or ischemia); perianal tearing or anal irregularities
Laboratory Tests That Might Be Ordered
Baseline Hgb and Hct can be abnormal, indicating anemia or thrombocytopenia; baseline values are measured to evaluate future blood loss
Leukocytosis with increased bands can indicate infection
Elevated INR/PT and PTT can indicate coagulopathy
Elevated BUN level can indicate UGIB
Fecal occult blood test can be positive in acute or chronic bleeding
Undercooked meat and raw fruits and vegetables can cause a false-positive result
Gastroccult test can identify blood in emesis or gastric aspirate
Type and cross-match of blood for possible blood transfusion
Other Diagnostic Tests/Studies
Endoscopy and enteroscopy will usually indicate the source of GI bleeding
Upper GI series to assess for the source of UGIB
Colonoscopy to identify the source of LGIB
Multi-Detector CT (MDCT) scan, MRI, or X-ray can indicate anatomical abnormalities or GI obstruction
Treatment Goals
Promote Optimum GI Physiologic Status and Reduce Risk for Complications
Assess for hypovolemia and shock by frequently checking vital signs for tachycardia and hypotension; administer supplemental oxygen, I.V. fluids, and blood transfusions, as ordered
Monitor I & O and maintain adequate hydration and nutrition
Administer prescribed medications; monitor treatment effectiveness and for adverse effects (consult a drug information resource for a complete list)
Provide a safe environment by keeping side/crib rails up and elevating the head of the bed; make frequent positional BP checks
Follow facility pre- and post-treatment protocols if the patient becomes a candidate for endoscopy or surgery for resolution of bleeding; reinforce pre- and post-treatment education and verify parental completion of facility informed consent documents
Provide Emotional Support and Educate
Assess patient and family anxiety level and coping ability; provide emotional support, educate, and encourage discussion about GI hemorrhage etiology if known, potential complications, treatment risks and benefits, and individualized prognosis
Encourage family visitation or rooming-in per facility protocol
Request referral, if appropriate, to a social worker for identification of local resources for support groups or in-home services
Request referral to a mental health clinician, if appropriate, for counseling the child (if age-appropriate) on stress reduction and parental counseling on strategies for coping with a child’s life-threatening condition
Red Flags
Red Flags Children with severe gastroesophageal reflux disease (GERD) can develop esophagitis with associated UGIB
Red Flags Newborns who swallow maternal blood during delivery can show S/S that mimic a GI bleed
Red Flags NSAIDs can cause gastritis, peptic ulcers, and UGIB in children
Food for Thought
A retrospective chart review of children presenting to the ED with hematemesis found that unwell appearance, history of melena, history of hematochezia, and/or a large quantity of fresh blood in vomitus were reliable predictors of clinically significant UGIB (Freedman et al., 2012)
What Do I Need to Tell the Patient’s Family?
Infants with bleeding secondary to allergic colitis from cow’s milk allergy respond well to dietary restrictions and proper formula
Continued medical surveillance is critical; seek immediate medical attention for new or worsening S/S
Description/EtiologyGastrointestinal (GI) hemorrhage is bleeding from any site in the GI tract (i.e., esophagus, stomach, small intestine, colon). Most cases of GI bleeding occur in the upper GI tract; upper GI bleeding (UGIB) is defined as GI bleeding above the ligament of Treitz (i.e., ligament that suspends the duodenum). The clinical presentation of GI bleeding ranges from asymptomatic to hypovolemic shock. An active GI bleed in a child can progress rapidly to hypovolemia and shock. Severe GI bleeding is rare among the pediatric population and therefore, the documented research is limited(Wolfram et al.; 2013).GI lesions (e.g., ulcers, varices) and mucosal irritation (e.g., esophagitis, gastroenteritis) are the most common causes of pediatric GI bleeding. Necrotizing enterocolitis and allergic colitis (e.g., cow’s milk protein allergy) are two common causes specific to children. Esophageal varices, gastritis, peptic ulcers, coagulopathy, and vascular malformations can all produce UGIB. Peptic ulcers can develop secondary to the stress of illness or from ingestion of some drugs (e.g., NSAIDs, steroids), caustic substances, or foreign bodies. Cancer is seldom the cause of pediatric GI bleeding.Method of treatment depends on bleeding location and severity; I.V. fluids, blood transfusion, oxygen, close monitoring of vital signs, and other supportive measures can be warranted. Stomach contents are aspirated through a nasogastric tube to determine if the bleeding is in the upper or lower GI tract. Endoscopy is performed to locate and evaluate the source of bleeding. Therapeutic endoscopy can resolve bleeding with thermal or mechanical techniques, or by injection of a sclerosing agent; however, if endoscopic therapy fails or the bleeding site is unknown, surgery might be necessary. Pharmacotherapy can include H2-blockers (e.g., ranitidine, cimetidine), antacids, cytoprotective agents (e.g., sucralfate), hormones/hormone analogues (e.g., vasopressin, terlipressin, somatostatin, octreotide), and β-blockers (e.g., propranolol).Facts and Figures
Ten percent to 20% of all referrals to pediatric gastroenterologists are for GI bleeding, and 6–20% of PICU patients have UGIB. Endoscopy identifies the bleeding source 90% of patients with UGIB if performed within 24 hours of onset, and colonoscopy identifies the bleeding source in 80% of patients with lower GI bleeding (LGIB).
Risk Factors
Gastritis increases risk for UGIB in children of all ages; other causes of GI bleeding vary according to age. Among infants, common causes include hemorrhagic disease secondary to vitamin K deficiency, anal fissure, and necrotizing enterocolitis. In older children, common causes include esophagitis, peptic ulcer disease, allergic colitis, juvenile polyps, Meckel diverticulum, rectal prolapse, and esophageal varices.
Signs and Symptoms/Clinical Presentation
Clinical presentation depends on the child’s age, etiology and location of bleeding, and whether bleeding is acute or chronic. Signs and symptoms (S/S) of acute GI bleeding can include hematemesis, melena (i.e., dark, tarry stools containing blood, indicating UGIB), hematochezia (i.e., bright red, bloody stools usually indicating LGIB), and tachycardia. Other S/S include diarrhea, abdominal tenderness or pain, anorexia, and irritability.
Assessment
Patient History
Ask about history of S/S (e.g., duration, progression, and type; jaundice; easy bruising; stool color changes)
Ask about recent travel, exposure to sick persons, and foods and drugs the child has taken, as some (e.g., fruit-flavored drinks, fruit juice, beets, licorice, bismuth subsalicylate [Pepto-Bismol], iron supplements) can mimic the appearance of bloody stool and/or hematemesis
Physical Findings of Particular Interest
Patient can have signs and symptoms of upper and lower GI bleeding, including tachycardia (blood loss); vomiting, epigastric pain, protruding abdomen, (Singhi et al; 2013)diarrhea, petechiae, echymoses and malformed blood vessels,(Singhi et al; 2013)and fever (infection); or an hepatomegaly, splenomegaly, or jaundice (liver disease)
Patients with UGIB may have melena, hematemesis, and hyperactive bowel sounds; hematochezia can be present if blood passes rapidly through the GI tract
Patients with LGIB can have bright red rectal blood; abdominal tenderness (intussusception or ischemia); perianal tearing or anal irregularities
Laboratory Tests That Might Be Ordered
Baseline Hgb and Hct can be abnormal, indicating anemia or thrombocytopenia; baseline values are measured to evaluate future blood loss
Leukocytosis with increased bands can indicate infection
Elevated INR/PT and PTT can indicate coagulopathy
Elevated BUN level can indicate UGIB
Fecal occult blood test can be positive in acute or chronic bleeding
Undercooked meat and raw fruits and vegetables can cause a false-positive result
Gastroccult test can identify blood in emesis or gastric aspirate
Type and cross-match of blood for possible blood transfusion
Other Diagnostic Tests/Studies
Endoscopy and enteroscopy will usually indicate the source of GI bleeding
Upper GI series to assess for the source of UGIB
Colonoscopy to identify the source of LGIB
Multi-Detector CT (MDCT) scan, MRI, or X-ray can indicate anatomical abnormalities or GI obstruction
Treatment Goals
Promote Optimum GI Physiologic Status and Reduce Risk for Complications
Assess for hypovolemia and shock by frequently checking vital signs for tachycardia and hypotension; administer supplemental oxygen, I.V. fluids, and blood transfusions, as ordered
Monitor I & O and maintain adequate hydration and nutrition
Administer prescribed medications; monitor treatment effectiveness and for adverse effects (consult a drug information resource for a complete list)
Provide a safe environment by keeping side/crib rails up and elevating the head of the bed; make frequent positional BP checks
Follow facility pre- and post-treatment protocols if the patient becomes a candidate for endoscopy or surgery for resolution of bleeding; reinforce pre- and post-treatment education and verify parental completion of facility informed consent documents
Provide Emotional Support and Educate
Assess patient and family anxiety level and coping ability; provide emotional support, educate, and encourage discussion about GI hemorrhage etiology if known, potential complications, treatment risks and benefits, and individualized prognosis
Encourage family visitation or rooming-in per facility protocol
Request referral, if appropriate, to a social worker for identification of local resources for support groups or in-home services
Request referral to a mental health clinician, if appropriate, for counseling the child (if age-appropriate) on stress reduction and parental counseling on strategies for coping with a child’s life-threatening condition
Red Flags
Red Flags Children with severe gastroesophageal reflux disease (GERD) can develop esophagitis with associated UGIB
Red Flags Newborns who swallow maternal blood during delivery can show S/S that mimic a GI bleed
Red Flags NSAIDs can cause gastritis, peptic ulcers, and UGIB in children
Food for Thought
A retrospective chart review of children presenting to the ED with hematemesis found that unwell appearance, history of melena, history of hematochezia, and/or a large quantity of fresh blood in vomitus were reliable predictors of clinically significant UGIB (Freedman et al., 2012)
What Do I Need to Tell the Patient’s Family?
Infants with bleeding secondary to allergic colitis from cow’s milk allergy respond well to dietary restrictions and proper formula
Continued medical surveillance is critical; seek immediate medical attention for new or worsening S/S
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