Gastrointestinal (GI) bleeding

Setia Budi S.

Division of Gastroenterology Child Health Department

Medical Faculty University of Hasanuddin
 Gastrointestinal (GI) bleeding

GI tract cover a wide a surface area & bleeding

can occur anywhere along the GI tract

GI bleeding is a medical emergency in pediatric

patients
 Pathophysiology
Coagulopathies
coagulation factor: Hemophilia A and B, using anticoagulan and
medicine (chlorampenicol, fenitoin, barbiturat, salisilat, ect)

Mucosal lesions
erosion or ulcer (esophagitis, gastritis, Mallory-Weiss tear, stress ulcer,
petic ulcer)

Portal Hypertension
portal sirculation, prahepatic lesion (porta vein trombosis and
splenicus), fibrotic and cirrhosis hepatic

Vascular lesions
herediter, chronic, reccurent tranfusion, GIT bleeding in family
(telangectasia hemorragic, Klippel Trenaunnay sindr)
 Evaluation of GIT bleeding
Source of bleeding
Other bleeding source ? (ENT, teeth, nasopharincs, )
Food and drugs : Fe, bismuth, commercial dyes, spinash, beet,
grape, chocolate,
Mother or infants (Apt-downey test) Squires RH, 1999

Bleeding characteristic
red blood hematemesis : masive bleeding
melena : bleeding > 2% of blood volume,
hematochezia (++) : masif upper GIT bleeding
BP, tachycardia, pale, peripher perfusion, sweat, delirium
bleeding (+++)
10 mmhg sistolic pressure, pulse 20x/min (supine to upright)
intravascular blood lost 15-20%
 Evaluation of GIT bleeding

Acute or chronic onset

Acute : no previous symptoms (hematemesis)
Chronic : reccurent melena +/- anemia
15% of intermittent and continue blood lost no dynamic changes
15% of acute blood lost blood pressure, pulse 10-20%

On going bleeding
Strick observation on pulse frequency, blood presure, and
respiratory rate (every 15 min)
 Identify the bleeding source

Hematemesis
recent or ongoing hemorrhage proximal to the ligament of Treitz

Hematochezia
bright red or maroon-colored stool & suggest that the bleeding is
from the colon
Brisk and significant upper GIT

Melena : a black, tarry stool

bleeding proximal to the ileocecal valve
ascending colon (<<) : slow colonic transit bacteria denature
the hemoglobin
 Etiology Upper GIT Bleeding

Neonate 1-2 years 2-5 years >5 years

Mom Blood swallow* Esophagitis* Stress ulcer* Stress ulcer*
Stress ulcer* Stress ulcer* Gastritis* Gastritis
Esophagitis Gastritis* Mallory-Weiss tear* Peptic ulcer
Hemorragic dis. Mallory-Weiss tear* Esophagitis Mallory-Weiss tear*
Vascular dis. Coagulapathy* Foreign body Esophageal varices
Duplication cyst Vascular dis. Vascular dis. Esophagitis
Nasogastric tube Duplication cyst Hemobilia Vascular dis.
Hemobilia

Squires RH, 1999

 Etiology Lower GIT Bleeding

Infants Older children

Anal fissure* Anal fissure*
Cows milk allergy* Intussuception*
NEC* Infection enterocolitis*
IBD (> 3-4 years)*
Swallowed maternal blood*
Juvenile polyps*
Vascular lesion
Meckel diverticulum*
Hirschsprung enterocolitis Vascular malformation
Intussuception Henoch Schonlein purpura
Infection colitis Intestinal duplicaton
. Sexual abuse
.

Squires RH, 1999; Cheng, 2001

 Nasogastric tube and lavage
Document presence of blood in the stomach
Classifying the severity of upper GI bleeding
Monitor the rate of bleeding & presence of active bleeding
Identify recurrent of bleeding

Decompress stomach & remove gastric acid

Clear nasogastric aspirate does not rule out upper GI bleeding
duodenal bleeding
icewater or saline ?

Preparation for endoscopic examination

 Prediction based on NGT aspirate

NGT aspirate ~ blood finding at endoscopy

Clear aspirate 20%
Coffee grounds aspirate 35%
Red blood aspirate 45%

Significance of clear NGT aspirate ~ endoscopic finding

Duodenal abnormalities 30%

Gastric abnormalities 45%
Esophageal varices 4%
Mallory-Weiss tear 3%
 What is the spesific
diagnosis and site of hemorrhagic
 Upper GI Tract Rontgenographic

Especially poor at identifying superficial lesions like

gastritis and esophagitis

The source of bleeding was identified in 45% patients

Identified abnormalities in 20% patient who had esophagitis or
gastritis
 Endoscopy

Endoscopic was the most accurate method of identifying

a source of bleeding, 80-90% cases

Recommended
the patient has been stabilized
within 24 hours of admission or onset of bleeding
Diagnostic and therapeutic
 Pathology
Upper GIT bleeding
Chronic esophagitis
Chronic active non-active
gastritis
Duodenitis
H. pylori infection
Metaplasia gastric esophagitis
Esophageal varices
Lower GIT bleeding
Chronic Colitis amoebic
Non specific colitis
Juvenile polyp/polyposis
Eosinophilic colitis (?)
Ulcerative colitis
IKA, RSCM (2004)
 Meckels Scan
Identification of functional gastric mucosa in an ectopic location
Meckels diverticulum, duplication cyst
99m Tc-pertechnetate scan

Bleeding scan
To better localize an intermittently bleeding site, small volume, site
not easily reachable with the endoscope
99mTc-labled Red Cells
Blood flow at least 0.1 ml/min

Angiography Bleeding
- is massive or chronic / recurrent bleeding
- In case where endoscopy and UGI r series have failed to identify
a source of bleeding
- Blood flow at least 0.5 ml/min
 How frequent the bleeding ?

Cow milk allergy (CMA) colitis is relatively frequent,

almost 100 %

Inflamatory bowel diseases (IBD) + 50 %

Infectious colitis + 75 %

H pylori infection seldom (+ 10 %)

 Therapeutic

General
Establish whether the child is stable hemodynamically
Resuscitation & general therapeutic modalities
Fluid (cristaloid, RL) and blood resuscitation must be started
immediately
Laboratory : hb, ht, platelet, serum electrolyte, blood
urea/creatinine, coagulation
Packed red cell, platelet

Nasogastric tube and lavage

Rectal bleeding : anal inspection & digital rectal exam

Rodgers BM, 1999; Cheng TL, 2001

 Therapeutic
Specific
Varices :
Octreotide (25 ug/jam 25 ug/4hour),
Sclerosing, ligation, sengtasken blakemore tube

Mucosal lesion
hyperemic, erosi, ulcer : antacid, H2 antagonist, PPI
bleeding ulcer : Clips, fibrin glue, adrenalin 1:10.000, ect
ulcerative colitis : antibiotic, corticosteroid, sulfasalazine
CMA colitis : eliminasi CM

Coagulopathies
Vit. K, FFP, ..

Therapeutic procedure : polipectomy,

 Surgical intervention

More than 85 ml/kg of blood is transfused within 1.5

hour and bleeding has not subsided

In case of secondary manifestation of another life

threatening disease
 Mortality

Mortality correlated with :

Initial level of Ht < 20% or Hb < 7 g/dl

Transfusion > 85 ml/kg without surgical
Failure to identify the source of bleeding
Presence coagulation disorder
Coexistense of another life threatening disease