GASTROINTESTINAL

BLEEDING
David A. Gremse, MD, FAAP, FACG
Professor and Chair of Pediatrics
University of Nevada School of Medicine
 Gastrointestinal Bleeding
 Hematemesis- Vomiting of bright red blood
 usually represents bleeding proximal to
the ligament of Treitz
 Hematochezia- bright red blood per rectum
 indicates a lower GI source of bleeding

 Blood has a laxative effect so with massive

bleeding the stool may be bright red
 Gastrointestinal Bleeding
 Blood streaks on the stool indicates anal outlet
bleeding
 Blood mixed with stool indicates bleeding source
higher than the rectum
 Blood with mucus indicates an infectious or
inflammatory disease
 Currant jelly-like material indicates vascular
congestion and hyperemia (intussusception or
midgut volvulus)
 Gastrointestinal Bleeding
 Maroon-colored stools indicate voluminous
bleeding proximal to the rectosigmoid area
 Melena, passage of black, sticky (tarry)
stools suggests upper GI tract bleeding, but
can be as distal as the right colon
 Hematemesis suggests a large bleed with
possible recurrence, melena alone indicates
less voluminous bleeding
 Causes of Upper GI Bleeding
 Common  Less Common
 Nasopharyngeal  Bleeding disorders
bleeding  Duplication cyst
 Erosive Esophagitis  Foreign body
 Peptic ulcer  Tube trauma
 Gastritis (H. pylori)  Vascular malformation
 Mallory-Weiss tear  Esophageal varices
 Prolapse gastropathy
 Causes of Lower GI Bleeding
 Common  Less Common
 Anal fissure  Meckel’s diverticulum
 Infectious colitis  Duplication cyst
Salmonella, Shigella,  Hirschsprung’s
Campylobacter, C.diff
enterocolitis
 Inflammatory bowel
disease
 Gangrenous intestine
 Intussusception
 Vascular malformation
 Upper GI source
 Clinical Findings in PUD
Neonatal Period
 Gastric ulcers are more common than
duodenal ulcers in neonates
 Spontaneous Perforation is a more
common presentation than bleeding
 Frequently associated with:
 Hypoxia, Sepsis, RDS, CNS disorder
 Clinical Findings in PUD
Infants and Toddlers
 Presenting symptoms:
 Vomiting

 Poor feeding

 Irritability during and after eating

 Abdominal distention

 Hematemesis, melena

 Commonly associated with underlying

disease in this age group
 Clinical Findings in PUD
Pre-Schoolers
 Periumbilical or generalized abdominal pain
 Vomiting after eating
 Nocturnal or early morning pain
 Gastric ulcers are as common as duodenal
ulcers
 Primary ulcers are as common as secondary
ulcers
 Clinical Findings in PUD
School Age
 Male: Female ratio is 3:1
 Burning epigastric pain
 Nocturnal pain
 Melena, hematemesis, fecal occult blood
 Primary ulcers are more common than
secondary ulcers
Pathophysiology of GI Bleeding
 Mucosal lesions
 Acid-peptic disease, drug-induced (NSAIDs),
Infectious (H. pylori), inflammatory bowel dz
 Portal hypertension
 Esophageal varices, hypertensive gastropathy
 Coagulopathy - Hemophilia, hepatic
coagulopathy, CHF w/hepatic congestion
 Vascular lesions - hemangiomas
 Causes and Effects of H Ion +

Backdiffusion
Lowflow states Drugs, EtOH Stress H. pylori Bile Reflux

Mucosal Barrier Break

H+

Parietal Cells

Release of histamine + Vasodilatation

Increased HCl and Pepsin Secretion
 Peptic Ulcer Disease
Diagnostic Evaluation
 History (medications, family history)
 Physical exam (include Hemoccult)
 CBC, type & screen for GI bleeding
 PT, PTT
 H. pylori antibody, fasting gastrin level
 Upper GI Series
 EGD
 Indications for EGD
 Hematemesis, Melena, Heme (+) stool
 Severe pain, weight loss
 Unexplained anemia
 Symptoms persist despite trial of
antisecretory therapy
 Evaluation of abnormal UGI series
 Evaluation of status of H. pylori
 Case #1 – UGI Bleeding
 12 YOWF with S/P splenectomy 2 yr ago for
Evan’s syndrome
 Weakness, pallor, melana x 2 days
 Exam – HR- 128, BP-86/54, tachycardic, pale,
abdomen nontender, nondistended, no
hepatomegaly
 Lab – H/H=6.8/19.1, WBC, 5.7; platelets,
115,000, PT=13.2 sec; AST, 38; ALT, 45; T.bili,
0.5; alk phos, 227
Esophageal varices
 Case #2 – UGI Bleeding
 11 YOWM previously healthy with 1 day h/o
fever, vomiting and diarrhea
 Emesis x 6 over past 24 hr, w/blood last 2 times
 Exam – HR- 84, BP-116/74, abdomen
nontender, nondistended, no hepatomegaly
 Lab – H/H=13.8/39.1, WBC, 8.7; platelets,
235,000, PT=12.2 sec
Prolapse Gastropathy
 Meckel’s Scan
 99mTc-Pertechnetate Scan - injected IV and
accumulates in gastric tissue - RLQ uptake
is diagnostic of Meckel’s diverticulum
 False (+) - bleeding lesions such as
Crohn’s disease, intussusception,
hemangioma, PUD
 False (-) - Barium, bladder overdistention,
no gastric mucosa in diverticulum
 99m
Tc- Labeled Red Cell Scan
 99mTc-sulfur colloid is added to a sample of
the patient’s blood cells and re-infused IV-
patient is scanned with gamma camera
 Half-life is short (2.5 min) so that after 10
minutes only 10% is left in the circulation
 99mTc accumulates at the bleeding site and

lights up on scan - can detect 0.1 ml/min

 GI Bleeding - Treatment
 ABCs - protect airway with hematemesis in an
obtunded patient
 IV access - two lines (0.9% NS in one line,
PRBC’s not compatible with dextrose)
 Transfuse for Hgb < 8 w/active bleeding
 NG lavage
 Antacids (1 ml/kg up to 30 ml q 2 hr)
 PPI 2 mg/kg loading dose, then 1 mg/kg/day
IV
 Drug Efficacy in Healing Ulcers
 Drug Regimen Ulcers Healed
 H2RA 4 weeks 8 weeks
 Cimetidine 40 mg/k/d 80% 90%
 Ranitidine 4-8 mg/k/d
 Famotidine1-2 mg/k/d
 PPIs
 Omeprazole 0.7-3 mg/k/d 85% 95%
 Lansoprazole 0.7-4 mg/k/d

 Sucralfate 40-80 mg/k/d 75% 86%

 ATLS Classification of Shock
Class Blood BP HR Cap Neuro
Loss refill
1 <15% WNL Up to WNL WNL
10-20%
2 20 – 25% Decreased >150 > 3 sec Alert

3 30 – 35% Decreased >150 > 3 sec Lethargic

4 40 – 45% Not >150 > 3 sec Obtunded

palpable
 Management
 Class 1, no anemia, no active bleeding on
lavage, may be followed up as outpatient
 Class 2, mild anemia, active bleeding may
be monitored on wards
 Class 3 or 4 admit to PICU, central line,
arterial line
 IVF boluses, transfusion as needed
 Management
 Iced saline? - with cooling, bleeding time
increases to 3 x control, clotting time
increases up to 60%, and PT can increase
to 2 x control, and can cause hypothermia
 NG tube is useful to monitor bleeding, but
not in treatment
 Therapeutic endoscopy (sclerotherapy)
useful in variceal hemorrhage
 Management - Octreotide
 Somatostatin analog - octreotide has a longer
half-life than somatostatin
 Decreases splanchnic blood flow and
gastrointestinal secretion
 Make a 1 g/ml drip - begin drip at a rate of 0.1
g/kg/min - increase to 0.5 g/kg/min until
bleeding stops, then wean rate
 Side effects - nausea, gas, hyperglycemia,
gallstones, elevated liver enzymes
 GI Bleeding – Summary
 Remember your abC’s
 IV access if bleeding is significant
 Plan diagnostic work-up based on
presentation
 Consider non-GI causes of blood in the GI
tract (e.g., swallowed blood)
 Question #1
 An 18-month-old boy passed a dark red stool four hours ago and
another bloody stool during physical examination. He has no fever,
vomiting, diarrhea, or constipation. His growth and development
have been normal. On physical examination, his pulse is 140/min,
respiratory rate 24/min, and blood pressure is 86/54 mmHg. The
abdomen is soft and nontender. Rectal examination reveals maroon-
colored stool that is guaiac positive. The remainder of the physical
examination is normal. Gastric aspirate is negative for blood.
Laboratory evaluation reveals hemoglobin 8 g/dL, hematocrit 26%.
Prothrombin time, partial thromboplastin time, and INR were
normal. After intravenous fluid administration and erythrocyte
transfusion, which of the following is most likely to be diagnostic?

A. Barium enema
B. Meckel radionuclide scan
C. Computerized tomography (CT scan) of the abdomen
D. Upper gastrointestinal series with small bowel follow through
E. Abdominal angiography
 Question #2
 A 6-week-old infant has done well since birth until blood and mucus
appeared in the stool for the past 3 days. He is taking his usual four
ounces of cow-milk formula per feeding without vomiting. He is
more irritable during defecation. Physical examination reveals that
the abdomen is soft and not distended. The hemoglobin is 10 g/dL.

 Which of the following is the most likely explanation for the findings
in this infant?

A. Hirschsprung disease
B. Meckel diverticulum
C. Anal fissure
D. Cow-milk protein colitis
E. Midgut volvulus