Key points

Introduction

Upper gastrointestinal (UGI) bleeding can generally be defined as bleeding proximal to the ligament of Treitz, which leads to hematemesis. More specifically, an UGI bleed is often characterized by vomiting bright red blood or coffee ground–like emesis. Melena, characterized by black, tarry stools, can also be a manifestation of UGI bleeding.

In the pediatric population, UGI bleeding has been noted to account for up to 20% of all GI bleeding in children. In the critical care setting, a large prospective study noted 6.4% of pediatric intensive care unit (PICU) admissions were secondary to UGI bleeding. Further study of the risk factors for UGI bleeding in critical care settings, such as the PICU, have found that comorbid conditions (ie coagulopathy, pneumonia, multiple trauma, and so forth) increase the risk for pediatric UGI bleeds, particularly in patients not given prophylactic therapy. Fortunately though, as noted by a recent study looking at emergency department data, most children presenting for care with UGI bleeds do not require hospitalization or intervention.

Introduction

Upper gastrointestinal (UGI) bleeding can generally be defined as bleeding proximal to the ligament of Treitz, which leads to hematemesis. More specifically, an UGI bleed is often characterized by vomiting bright red blood or coffee ground–like emesis. Melena, characterized by black, tarry stools, can also be a manifestation of UGI bleeding.

In the pediatric population, UGI bleeding has been noted to account for up to 20% of all GI bleeding in children. In the critical care setting, a large prospective study noted 6.4% of pediatric intensive care unit (PICU) admissions were secondary to UGI bleeding. Further study of the risk factors for UGI bleeding in critical care settings, such as the PICU, have found that comorbid conditions (ie coagulopathy, pneumonia, multiple trauma, and so forth) increase the risk for pediatric UGI bleeds, particularly in patients not given prophylactic therapy. Fortunately though, as noted by a recent study looking at emergency department data, most children presenting for care with UGI bleeds do not require hospitalization or intervention.

Cause

Common and unusual causes of UGI bleeding depend on patient age, as noted in Table 1 . In addition, there may be geographic variability that can dictate the need for endoscopy (ie, prevalence of Helicobacter pylori ). Outside of the United States, variceal bleeding may be more common in children, increasing their likelihood of requiring endoscopy and/or intervention to ensure hemostasis. For example, schistosomiasis is a common infection in many parts of the developing world that can lead to periportal fibrosis, cirrhosis, and portal hypertension without overt hepatocellular injury. In areas where schistosomiasis is prevalent, such as sub-Saharan Africa and Southeast Asia, hepatic infestation and the possibility of variceal bleeding needs to be considered when presented with a patient with UGI bleeding. In these children, liver chemistries may return as normal and the singular presenting issue may strictly be the hematemesis.

Neonates

In the first few months of life, UGI bleeding is uncommon; however, it can still occur. The most common cause of UGI bleeding in newborn infants is swallowed maternal blood from breastfeeding. An Apt test can be done to differentiate maternal blood from fetal blood by denaturing adult hemoglobin with sodium hydroxide (NaOH) causing a color change.

Another consideration in this age group is vitamin K deficiency, particularly in babies born outside of the hospital setting and/or not receiving vitamin K prophylaxis at birth. In severely ill newborns, stress gastritis and ulcers can also occur. Coagulopathy from infections, hematologic issues, or liver disease can present with UGI bleeding in all age groups. Intestinal duplications and vascular anomalies can present as acute UGI bleeds as well. On rare occasions, milk protein intolerance may present with UGI bleeding; but lower GI bleeding/hematochezia would be the more common presentation.

Infants/toddlers

Possible causes of UGI bleeding in the infant and toddler age range overlap with neonatal causes. Furthermore, in this more mobile and inquisitive population, foreign bodies must be considered more commonly as well as caustic ingestions. Also, Mallory-Weiss tears, or esophageal lacerations from chronic retching and/or vomiting, is another possible cause. In addition, chronic use of medications, such as nonsteroidal antiinflammatory drugs (NSAIDs) used to treat febrile viral illnesses common in toddler populations, can lead to ulcers and gastritis with subsequent hematemesis.

Rare causes of hematemesis in this age group can include Helicobacter pylori , Dieulafoy lesions, telangiectasias, hemangiomas, vascular malformations, duplications cysts, parasites, vasculitis, and gastric polyps.

Older children/adolescents

In this age group, UGI bleeding causes are similar to that of adults. The most common considerations in otherwise healthy patients presenting with bright-red or coffee-ground emesis includes Mallory-Weiss tears, gastritis, esophagitis, peptic ulcers, and varices. Coughs, which are usually thought of as a benign occurrence, can also lead to hematemesis secondary to a Mallory-Weiss tear. Unusual causes, though rare, still need to be considered in the differential, as it is with younger infants and children.

Evaluation

Initial evaluation and assessment of patients presenting with UGI bleeding should focus on the achievement of hemodynamic stability ( Fig. 1 ). Vital signs, such as heart rate, blood pressure, and capillary refill, should be continually monitored; the need for early fluid resuscitation should be assessed and initiated. This is particularly important in the pediatric population, which is more susceptible to hypovolemia. For severe, acute UGI bleeding in children, local pediatric gastroenterologists as well as GI surgeons should be consulted for help with the management and planning for interventions to effect hemostasis.

Algorithm for evaluating hematemesis.

While patients are being stabilized, a detailed history should be obtained to determine the initial presentation, time course, extent of bleeding, associated signs and symptoms, and other possible medical conditions, such as recent viral gastroenteritis or chronic illnesses. Attention to the intake of breast milk or colored foods or drinks also needs to be considered. History regarding particular GI symptoms, such as poor feeding and irritability in neonates or dyspepsia, dysphagia, abdominal pain, or weight loss in older children, is important. Timing and presence of melena should also be determined.

Associated signs and symptoms, such as jaundice or easy bruising or recurrent and persistent epistaxis, should all be part of the history to help tease out the underlying cause of UGI bleeding, which could include liver diseases or hematologic diagnoses. A thorough physical examination is also obviously vital.

Obtaining a good medication history is also vital in assessing these patients. Certain medications, such as NSAIDs or corticosteroids, can predispose patients to ulcerations. Other medications, such as tetracycline, can lead to pill esophagitis. And yet other medications can predispose patients to prolonged bleeding, such as anticoagulants. Additionally, medications, such as beta-adrenergic antagonists, may hide appropriate hypovolemic responses.

To aid in assessing patients with UGI bleeding, laboratory evaluation should be done for more worrisome presentations. Testing should include a complete blood count, complete metabolic panel, and possibly coagulation studies as well. If the blood loss is significant enough, a type and cross-match blood sample should also be obtained in case of need for blood transfusion.

Radiologic tests may be helpful in assessing UGI bleeding, particularly if a foreign body is suspected. For this, a plain radiograph should suffice. If liver disease is suspected, obtaining an abdominal ultrasound to rule out splenomegaly and portal hypertension can be a useful diagnostic tool. Generally speaking, an UGI series with contrast should not be performed in patients with acute UGI bleeding because this may delay or the hamper performance of subsequent procedures, such as endoscopy, angiography, or surgery.

Interventions

Lavage via nasogastric or orogastric tube has been described as a useful technique in assessing unexplained and significant UGI bleeding. Confirmation of a UGI bleed can be obtained by the return of bright red blood or coffee grounds on lavage; however, no therapeutic actions can be pursued with lavage. It is also important to note that in adult data, up to 15% of patients with active UGI bleeding can have a negative lavage. In the past, ice water lavage was used with the hope of causing some vasoconstriction, leading to a slowing of UGI bleeding; however, this practice is no longer recommended and may actually be especially harmful, causing hypothermia, particularly in neonates and infants.

Acid suppression, although not well studied in the pediatric population, is recommended in pediatric UGI bleeds. Adult data support the role of acid suppression with a proton-pump inhibitor (PPI). PPI usage in adults with active UGI bleeding has been shown to minimize the risk of rebleeding and decreases the length of the hospital stay. A meta-analysis found PPI therapy in adults resulted in reduced rates for rebleeding, surgery, and deaths when dealing with acute nonvariceal bleeding. In a recent systematic review of critically ill pediatric patients, the use of PPIs showed some benefit in preventing UGI bleeding.

Adjunctive therapy with somatostatin or octreotide can be used in active or difficult-to-control UGI bleeding. In adults, these medications are particularly effective in variceal bleeding but have also been helpful for nonvariceal bleeding. No specific guidelines exist for the use of somatostatin or octreotide in the pediatric population; but for difficult-to-control bleeding, it is commonly given initially as a bolus of 1 μg/kg body weight to a maximum of 100 μg, then followed by a continuous intravenous (IV) infusion of up to 1 μg/kg/h.

In adult UGI bleeding, prokinetics, such as erythromycin or metoclopramide, are used to try and clear the stomach of debris, food particles, blood, and clots, particularly in severe bleeding. There are no data though to support the use of these agents in the pediatric population.