Approach to a child with hematemesis or melena
- 1. Approach to a child with hematemesis or melena Avijeet k. Mishra 1st year Resident Guide Dr Surya Bahadur Thapa DOCH
- 2. Contents Introduction Etiology Initial assessment and stabilization History Physical examination Investigations Management summary
- 3. Case A 32 months old male presented to us with a history of 2 days of abdominal pain , 3 episodes of black colored stool and 1 episode of fresh blood mixed with feces small in quantity without any similar past history. He had uneventful neonatal period and no history of rashes or bleeding from other sites.
- 4. Introduction Upper gastrointestinal bleeding- Bleeding from a site proximal to the ligament of Treitz Hematemesis is the cardinal sign Some may present with melena Lower gastrointestinal bleed- Bleeding from site distal to the ligament of Treitz Hematochezia is the usual presentation
- 5. Contd.. Hematemesis- Vomiting of blood which may be red or coffee grounds Melena- Passage of black tarry stools Action of digestive enzymes and bacteria change the color of stool to black tarry and foul smelling Hematochezia Passage of fresh blood per anus, usually in or with stool
- 6. Etiology Neonate Swallowed maternal blood - During delivery - From mothers nipple Coagulopathy - Hemorrhagic disease of the newborn - Septicemia, DIC - Hemophilia
- 7. Contd Stress ulcers/ gastritis critically ill newborns Drug intake -by mother: warfarin, aspirin -by neonate: indomethacin, steroids Vascular malformation- hemangioma, AV-malformation Duplication cyst Gastrointestinal polyposis syndrome
- 8. Contd.. Infant Mucosal erosion : -Reflux esophagitis -Pyloric stenosis Coagulation disorders Bacterial/amoebic enteritis, Intussusception, Mid gut volvulus, Meckel's diverticulum, Milk protein allergy, AV malformation
- 9. Contd.. Children Swallowed epistaxis Reflux esophagitis Gastric erosion/ gastritis/ peptic ulcer Esophageal varices Mallory-Weiss syndrome Coagulopathy Dysentery, intussusception, volvulus, Meckels diverticulum, colonic polyps, HSP
- 10. Contd.. Adolescents Swallowed epistaxis Gastric erosion/ gastritis/ peptic ulcer (drugs, H. pylori infection, stress- severe systemic disease, burn, raised ICP) Mallory Weiss tear Esophageal varices Inflammatory bowel disease, dysentery, colonic polyps Vascular lesions- telangeictasia, angiodysplasia, hemangioma, AV malformation
- 11. Contd. At our center out of 83 patients with gastrointestinal bleeds undergoing endoscopy, 40 were found to have esophageal varices, 8 had gastric erosion , 1 had polyp and 34 had normal endoscopy
- 12. Initial assessment and stabilization As for any other emergency the first priority should be to assess the circulation, breathing and airway of a patient presenting with UGIB Most important aspect of evaluation is to determine the degree and rapidity of blood loss Orthostatic changes in BP(more than 10 mm Hg) suggest a moderate bleed(15-20% blood loss) and warrant a more aggressive approach to management Presence of signs of shock (tachycardia, prolonged CRT, cold clammy skin, supine hypotension) indicates severe bleed of more than 25-30% of blood loss and a need for immediate volume expansion and stabilization before proceeding to a diagnostic algorithm
- 13. contd.. 1. Whether actual blood loss or ingested substances Hematemesis food coloring red candy colored gelatin beets tomato skin rifampin phenytoin Melena bismuth iron preparations licorice spinach grapes blueberries charcoal
- 14. Contd - For detecting blood in vomitus or nasogastric aspirate Gastroccult test is used 2. In neonate Whether patients own blood or swallowed blood Apt-Downey test is used to differentiate
- 15. Contd 3. Is there a pulmonary, oral or ENT source of bleed? - Epistaxis, sore throat, dental procedures or tonsillectomy - Hence these areas must be explored to rule out in cases of doubt 4. Level of bleeding - Acute onset hematochezia or melena- level of bleeding can be confirmed by the passage of a nasogastric tube - Presence of blood in stomach and clearing of nasogastric aspirate with lavage are diagnostic of UGIB
- 16. Focused history Age of patient Magnitude and duration Color and amount of hematemesis/ melenous stool Associated GI symptoms :- vomiting, diarrhea, pain Associated systemic symptoms :- fever, rash, joint pains, dizziness, palpitations
- 17. Contd.. Sudden onset of bright color hematemesis and melena of large amount: Esophageal varices Gradual onset chronic, mild hematemesis and melena: Acid peptic disease Preceding repeated forceful vomiting and retching: Mallory Weiss syndrome
- 18. Contd.. Acid regurgitation, nausea, vomiting, water brash, retrosternal pain: Reflux esophagitis Anorexia, nausea, vomiting and epigastric pain with relation to food: Peptic ulcer Bloody diarrhea, vomiting, abdominal pain, fever: Dysentery History of easy bruising or bleeding: coagulation, platelet dysfunction or thrombocytopenia
- 19. Contd.. History of drug intake: NSAIDS, corticosteroids, Mucosal irritants, iron preparation: Gastritis. Poisoning : Paracetamol, iron. Risk factors for portal HTN: umbilical sepsis / catheterization, jaundice, liver disease- Esophageal varices H/o chronic cough, recurrent lung infections: Cystic fibrosis, Bronchiectasis.
- 20. Contd Review of Systems GI disorders Liver disease Bleeding diathesis Family History GI disorders (polyps, ulcers, colitis) Liver disease Bleeding diathesis
- 21. Physical examination Vital signs :- PR, BP, RR, CRT Pallor, diaphoresis, confusion, obtundation, tachycardia, tachypnea Shock. Acute losses of 10-25% of blood volume cause tachycardia, narrow pulse pressure and postural hypotension. Earliest sign to increase is HR
- 22. Contd.. Pallor- Increased paleness will point towards ongoing blood loss Icterus- chronic liver disease Skin- petechiae, Purpura, ecchymoses, vascular malformations, stigmata for chronic liver disease like spider angioma, palmar erythema Examination of nose, oral cavity and throat
- 23. Contd.. Gastrointestinal examination 1. Epigastric tenderness acute gastritis or peptic ulcer disease 2. Protruding abdomen, prominent blood vessels and Hepatosplenomegaly portal hypertension and bleeding from esophageal varices 3. Splenomegaly- Extrahepatic portal vein obstruction(EHPVO) 4. Examination of perineum and rectum
- 24. Investigations In an emergency setting only a few tests are essential in the beginning to evaluate UGIB CBC PT/INR APTT LFT Blood grouping and Cross matching Further investigations 1. abdominal USG- EHPVO, portal hypertension due to liver disease, large vessel anomalies, splenic artery aneurysm
- 25. Contd.. 2. Endoscopy- - UGI endoscopy is the gold standard for diagnosis and treatment of UGIB - Procedure of choice for all patients with UGIB. - In the skilled hands diagnosis of etiology in 85-90% of cases - Contraindicated in in hemodynamically unstable patients 3. CT angiography - Vascular malformations beyond the duodenum , in areas not accessed by routine UGI endoscopy
- 26. Contd.. 4. Nuclear scintigraphy- - In persistent bleeding in whom endoscopy fail - Useful only if the rate of bleeding exceeds 0.1 ml/min 5. Angiography- - Celiac/ superior mesenteric artery angiography is used selectively in children with non-variceal bleeding eg from peptic ulcer, that obscures endoscopic evaluation and therapy - Also important in hemobilia, splenic artery aneurysm and some types of vascular malformation - Bleeding must be 0.5 ml/min to be detected by angiography
- 27. Management The initial steps in the management of severe UGIB include assessment, resuscitation, re- evaluation, identification of the cause and source of bleeding and commencing appropriate treatment Resuscitation and stabilization 1. Circulation- large bore venous access to restore blood volume crystalloids initially blood transfusion
- 28. Contd. Blood transfusion- - Rate depends on severity, continuing active bleeding and co-morbidities - BT not needed in hemodynamically stable patient that has hematocrit above 24% - Overtansfusion should be avoided in variceal bleed 2. Airway -Intubation in uncontrolled massive hematemesis to prevent aspiration and facilitate endoscopy if necessary 3. Breathing Supplemental oxygen
- 29. Contd.. Reassessment and monitoring- -Vitals should be monitor every 10- 15 minutes till stabilized -Then hourly for 24 hours after bleeding stops Nasogastric aspiration- Aspiration and saline lavage indicated in all patients with UGIB to confirm - Presence of intragastric blood - Rate of gross bleeding - Check for ongoing or recurrent bleeding - Clear gastric field for endoscopic visualization - Prevent aspiration - Prevent hepatic encephalopathy in patients of cirrhosis
- 30. Contd Correction of coagulopathies- - Vitamin k given empirically - Coagulopathy with INR >1.5 or abnormal aPTT- FFP Pharmacotherapy 1. Variceal bleed- Octeotride- Drug of choice for variceal bleed Acts by decreasing splanchnic blood flow Vasopressin, Terlipressin Somatostatin 2. Prokinetic agents- Erythromycin, Metoclopramide 3. Mucosal bleed- PPI, H2 blocker
- 31. Contd. Endoscopic techniques 1. Variceal bleed- Endoscopic sclerotherapy is the mainstay of treatment in this group Endoscopic variceal ligation 2. Nonvariceal bleed Injection adrenaline and saline Endoclip devices Balloon tamponade Sengstaken-blakemore tube Used in whom bleeding continues despite pharmacotherapy and endoscopic methods
- 32. Case Our case presented to us in the ER. At presentation he was an average build child with pallor and vitals of T-98*F, PR- 170, BP- 90/60, RR- 36. He was pale and anicteric. On per abdomen he had splenomegaly of about 3 cm. Rest of the exam was normal. Lab investigations- Hb- 5.7, TLC 13,000, platelets 17,600 LFT-N , RFT- N PT/INR- N, aPTT- N
- 33. Contd USG abdomen- splenomegaly, N hepatic echotexture, thickened wall of extrahepatic portal vein CT portogram- portal cavernoma with multiple collaterals at splenic hilum, peri-cholecystic, peri-pancreatic region UGI endoscopy- grade 3 varices
- 34. Summary UGI bleeding is a potentially life threatening emergency requiring an appropriate diagnostic and therapeutic approach Therefore primary focus in a child with UGI bleed is resuscitation and stabilization followed by a diagnostic evaluation In infants and toddlers mucosal erosion is the most common cause while in older children variceal bleeding due to EHPVO is most common UGI endoscopy is the most accurate and useful diagnostic tool to evaluate UGI bleed Treatment depends on the cause
- 35. Reference Indian journal of pediatrics Pediatric in review Nelson textbook of pediatrics www.Wikipedia.com