Upper GI Bleed

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.