Understanding Upper GI Bleeding in Children

1. Sameer Lapsia, MD Anupama Chawla, MD Stony Brook Children’s Hospital Reviewed by Christine Waasdorp Hurtado, MD of the Professional Education Committee Upper GI Bleed

2. Definition • Upper GI bleeding is defined as bleeding in the gastrointestinal tract proximal to the ligament of Treitz Ligament of Treitz

3. Epidemiology • UGI bleeding in children is uncommon. • Studies report incidence in the PICU to be between 6-25%1 • 5% of upper endoscopies are performed due to an upper GI bleed2 • Life-threatening UGI bleeding occurs in only 0.4% of children3 • Chaibou M, Tucci M, Dugas MA. Clinically significant upper gastrointestinal bleeding acquired in a pediatric intensive care unit: a prospective study. Pediatrics. 1998; 102:933-938. • Franciosi JP, Fiorino K, Ruchelli E. Changing indications for upper endoscopy in children during a 20-year period. JPGN. 2010; 51:443-447. • Gilger MA & Whitfield KL. Upper Gastrointestinal Bleeding. In Walker’s Pediatric Gastrointestinal Disease 5 Volume 2. Shelton, CT: People’s Medical Publishing House.1

4. Definitions • Hematemesis • Vomitus of frank red blood • Usually indicates a more rapidly bleeding lesion • Coffee ground emesis • Due to the coagulative effect of gastric acid on blood • It is usually a slower bleed therefore allowing acid and blood to interact http://www.healthysimulation.com/wp-content/uploads/2011/01/2.png

5. Definitions • Melena • Black, tarry stools • Can be produced by relatively small amounts of blood (50-100 cc) in the stomach • Can persist for 3-5 days following an acute bleed • Black color most likely due to hematin, the oxidative product of heme following interaction with intestinal bacteria http://www.medicalassessment.com/terms.php?R=642&L=B

6. Blood or not blood?: That is the question • Many items can appear as blood if vomited such as foods containing red food coloring (Jelly, Kool Aid), tomatoes, strawberries, and beets • Many items can appear as melena such as spinach, licorice, grape juice and certain medications such as Pepto-Bismol (due to bismuth) and Iron • Question is best answered by performing a guiac or gastroccult

7. Guaiac • Guaiac is a colorless compound that turns blue when placed in contact with substances (such as heme portion of hemoglobin) that have peroxidase activity and are then exposed to hydrogen peroxide • “False-positives” can occur with foods containing peroxidase activity such as red meat, melons, grapes, radishes, turnips, cauliflower, and broccoli • “False-negative” can occur in patients taking Vitamin C due to its anti-oxidant properties

8. Fecal occult blood tests • Gastroccult (Beckman Coulter, Inc) is based on the reaction of alpha guaiaconic acid with hydrogen peroxide in the presence of heme. • Especially useful when testing gastric aspirates as it measures pH as well • Hemoccult (SmithKline Diagnostics) uses intact heme-iron compounds to detect the presence of blood • HemeSelect (SmithKline Diagnostics) uses a immunochemical test that recognizes sequences of antigens found on the globin chains of hemoglobin • HemoQuant (BioSafe Medical Technologies) quantitatively measures blood through fluorometric assays that provide values for heme and heme-derived porphyrins in stool

9. Etiologies of UGI Bleeding:By Age, in relative order of frequency

10. Neonatal UGI Bleed • Swallowed maternal blood can present as hematemesis in the first few days • Apt test can be used to distinguish between maternal and newborn blood • Hematemesis may be the presenting symptom in hemorrhagic disease of the newborn secondary to vitamin K deficiency • Usually presents Days 1-5 of life • If bleeding persists, consider other bleeding disorders such as clotting factor deficiencies, e.g. von Willebrand’s disease

11. Neonatal UGI Bleed • Sensitivity to milk and soy proteins can present as hematemesis • Hematochezia is the more common presentation • Uncommon etiologies of neonatal UGI bleeding include pyloric stenosis, antral/duodenal webs, and indomethacin use • Shock causing ischemic mucosal injury from various causes including sepsis can lead to significant UGI bleed

12. Neonatal UGI Bleed Upper GI series view of the stomach shows a linear lucency consistent with an antral web. Barium flows distally without evidence of significant obstruction4 Noel R, Glock M, Pranikoff T. Nonobstructive antral web: an unusual cause of excessive crying in an infant. JPGN. 2000; 31:439-441.

13. UGI Bleed in Infants • Stress gastritis and ulceration can occur in critically ill neonates and infants resulting in UGI bleeds • Causes of stress and mucosal injury: • Surgery • Burns • Infections (both viral and bacterial) • Medications • Ischemia • Mechanical trauma from foreign bodies or enteral feeding tubes • Tumors

14. UGI Bleed in Infants: Differential • Acid-peptic disease, such as esophagitis, gastritis, and ulcer • Other findings include irritability with feeds, feeding refusal, and spitting up episodes • Eosinophilic esophagitis • Opportunistic infections such as cytomegalovirus, herpes, and fungal infections

15. UGI Bleed in Infants • Vascular anomalies are seen less often in the GI tract than the skin and soft tissues • Symptomatic hemangiomas of the gut GI system are rare and can present with significant bleeding5 • Large lesions that do not respond to prednisone may be treated with Interferon alfa-2b Khanna S, Kanojia RP, Menon P. Small bowel hemangiomas: diagnostic role of capsule endoscopy. Journal of Indian Association of Pediatric Surgeons. 2010; 15:101-103.

16. UGI Bleed in Infants • Anatomic abnormalities such as duplication cysts can cause UGI bleeding as these lesions contain gastric mucosa that can ulcerate and bleed http://www.clinicalimagingscience.org/article.asp?issn=2156-7514;year=2011;volume=1;issue=1;spage=19;epage=19;aulast=Herliczek

17. UGI bleeding in children and adolescents • Mallory-Weiss tear can occur as a result of forceful vomiting and is the most common cause of minor UGI bleeding in children http://www.gastrohep.com/images/image.asp?id=440

18. UGI bleeding in children and adolescents • Peptic mucosal injury can occur via several mechanisms including NSAID use, infection with Helicobacter pylori, and stressors listed before Diffuse nodular gastritis from H. Pylori infection http://www.tropicalgastro.com/printerfriendly.aspx?id=494

19. UGI bleeding in children and adolescents • Variceal bleeding • Most common cause of severe UGI bleeding in children • Most common location is the esophagus • Due to high-pressure, turbulent flow in the thin-walled superficial vessels of the distal esophagus • Bleeding spontaneously stops in 50% with re-bleeding in 40% • Nonspecific abdominal pain may precede variceal bleeding for up to 48 hours • May present as either hematemesis or melena

20. Varices Esophageal varices with red wale sign (longitudinal red streaks on varices indicated a recent bleed) Esophageal varices http://www.gastrointestinalatlas.com/English/Esophagus/Varices/varices.html

21. Causes of UGI bleeding in children & adolescents • Foreign body ingestion usually from a sharp object such as a safety pin • Caustic ingestion, however, this is usually a late finding • Crohn’s disease of the upper GI tract

22. Rare causes of UGI bleeding in children and adolescents • Gastric hemangiomas • Dieulafoy lesion6 • Gastric/duodenal vasculitis • Ruptured pancreatic pseudocyst • Gastric polyps • Leiomyosarcoma/teratoma Ibarullah M & Wagholikar GD. Dieulafoy’s lesion of duodenum: a case report. BMC Gastroenterology. 2003; 3:2.

23. Patient comes in with an Upper GI bleed… • ABCs are always important (Airway Breathing Circulation) • If hemodynamically unstable, immediate management includes fluid resuscitation and possible blood transfusions • If the patient remains unstable after receiving a blood transfusion of >85 cc/kg then emergency exploratory surgery is indicated • Note that overexpansion of blood volume can worsen variceal bleeding

24. Patient comes in with an Upper GI bleed… • Once the patient is hemodynamically stable, further workup is warranted3

25. Dermatological Clues • Skin findings in liver disease include caput madusa (black arrows), spider angiomata (red arrow), and jaundice http://radiographics.rsna.org/cgi/content-nw/full/21/3/691/F10 http://www.skinsight.com/adult/spiderAngioma.htm

26. Dermatological Clues • Other skin lesions include: hemangiomas (red arrow) and telangiectasias (blue arrow) which can also be present in the GI tract

27. Patient comes in with anUpper GI bleed… • Gastric aspiration is a useful indicator of UGI bleeding • Saline at room temperature is best used for gastric lavage • Bloody aspirate indicates active bleed • Clear aspirate does not eliminate bleeding from the duodenum http://www.secondsealconfidence.com/pwpcontrol.php?pwpID=6944&PHPSESSID=b6b8e022c2c12e8fbe011010626a5028

28. Upper Endoscopy Preferred method to evaluate the upper GI tract to determine the etiology of bleeding • Can determine the cause of UGI bleed in 90% of cases • 5 most common findings of UGI bleed via endoscopy are duodenal ulcer (20%), gastric ulcer (18%), esophagitis (15%), gastritis (13%), and varices (10%)7 • Most UGI bleeds in children will resolve spontaneously • Indicated when it will influence clinical decision making and therapeutic intervention • Contraindicated if patient is clinically unstable Cox K, Ament ME. Upper gastrointestinal bleeding in children and adolescents. Pediatrics. 1979; 63:408-413.

29. PillCam ESO • Capsule endoscope that can be used to diagnose esophageal pathology however can not provide therapeutic intervention

30. Radiographic Studies • Radiographic studies have limited use in diagnosing UGI bleeding in children • Abdominal U/S with Doppler may be useful to evaluate portal hypertension • Angiography useful only if bleeding is occurring at a rate of 0.5 cc/min or more • Localizes site of bleeding • Place “coils” for embolization of a bleeding vessel • Can be useful over upper endoscopy in patients with hemobilia

31. Treatment • ABC’s always important initially! • For acid-peptic disease treat with acid suppression medications • Antacids • H2 receptor antagonists • Proton pump inhibitors • Octreotide and vasopressin can be useful to reduce splanchnic blood flow in patients with severe UGI bleeding

32. Treatment • Endoscopic treatment includes electrocoagulation, laser photocoagulation, argon plasma coagulation, injection of epinephrine and sclerosants, band ligation, and mechanical clipping • Endoscopic treatment of variceal bleeding includes either injection sclerotherapy or variceal banding • Exploratory laparotomy may be required in patients with uncontrolled bleeding for both diagnostic and therapeutic intervention • Portosystemic shunting procedure may be indicated for severe gastroesophageal varices to address the underlying portal hypertension

33. References • Chaibou M, Tucci M, Dugas MA. Clinically significant upper gastrointestinal bleeding acquired in a pediatric intensive care unit: a prospective study. Pediatrics. 1998; 102:933-938. • FranciosiJP, Fiorino K, Ruchelli E. Changing indications for upper endoscopy in children during a 20-year period. JPGN. 2010; 51:443-447. • Gilger MA & Whitfield KL. Upper Gastrointestinal Bleeding. In Walker’s Pediatric Gastrointestinal Disease 5 Volume 2. Shelton, CT: People’s Medical Publishing House. • Noel R, Glock M, Pranikoff T. Nonobstructive antral web: an unusual cause of excessive crying in an infant. JPGN. 2000; 31:439-441. • Khanna S, Kanojia RP, Menon P. Small bowel hemangiomas: diagnostic role of capsule endoscopy. Journal of Indian Association of Pediatric Surgeons. 2010; 15:101-103. • Ibarullah M & Wagholikar GD. Dieulafoy’s lesion of duodenum: a case report. BMC Gastroenterology. 2003; 3:2. • Cox K, Ament ME. Upper gastrointestinal bleeding in children and adolescents. Pediatrics. 1979; 63:408-413.