Approach to a patient with GI bleeding

• Vomiting of fresh blood or “Coffee-grounds” (blood altered by gastric acid).

Hematochezia

• Passage of stools containing red blood rather than tarry stools.

Melena

• Refers to black tarry stools that usually result from upper GI bleeding.
• Represent bleeding anywhere above the ileocecal valve.

Causes Of G.I. Bleeding

 Neonates

• Most common causes :
  • Swallowed maternal blood
  • Bacterial enteritis
  • Milk protein allergies
  • Intussusception
  • Anal fissures
  • Lymphonodular hyperplasia.
• Erosions of the esophageal, gastric, and duodenal mucosa
• Some drugs:
  • NSAIDs, heparin, and tolazoline, used for persistent fetal circulation.
  • Indomethacin, used for patent ductus arteriosus in neonates
  • Maternal medications like Aspirin, cephalothin, and phenobarbital
  • Dexamethasone – Stress ulcers in newborns
• Rarer causes of GI bleeding in a neonate include
  • Volvulus
  • Coagulopathies
  • Arteriovenous malformations
  • Necrotizing enterocolitis (especially in pre-term infants)
  • Hirschsprung enterocolitis
  • Meckel diverticulitis

Infants

• GI mucosal lesions and irritations
  • includes esophagitis, gastritis, duodenitis, ulcers, colonic polyps, and anorectal disorders.
• Intussusception
• Other causes
  • Infectious diarrhea
  • Midgut volvulus
  • Meckel diverticulum
  • Arteriovenous malformation
  • GI duplication.
• Rare causes
  • Foreign body ingestions
  • Variceal disease
  • Coagulation disorder(hemorrhagic disease of new born)

Children

Common Causes:

• Bacterial enteritis
• Anal fissure
• Colonic polyps
• Intussusception
• Peptic ulcer/gastritis
• Swallowed epistaxis 
• Prolapse (traumatic) gastropathy 2° emesis
• Mallory-Weiss syndrome

Rare Causes:

• Esophageal varices
• Esophagitis
• Meckel diverticulum
• Lymphonodular hyperplasia
• Henoch-Schönlein purpura
• Foreign body
• Hemangioma, arteriovenous malformation
• Sexual abuse
• Hemolytic-uremic syndrome
• Inflammatory bowel disease
• Coagulopathy

Adults

Common Causes

• Bacterial enteritis
• Inflammatory bowel disease
• Peptic ulcer/gastritis
• Prolapse (traumatic) gastropathy 2° emesis
• Mallory-Weiss syndrome
• Colonic polyps

Rare causes

• Hemorrhoids 
• Esophageal varices
• Esophagitis
• Telangiectasia-angiodysplasia
• Graft versus host disease

Adolescents

• The most common causes of upper GI bleeding are duodenal ulcers, esophagitis, gastritis, and Mallory-Weiss tears.
• Lower GI bleeding most likely is caused by inflammatory bowel disease, colonic polyps, hemorrhoids, anal fissures, or infectious diarrhea

Other causes

• Gastroesophageal reflux disease (GERD)
• Stress ulcers
• Sexual trauma

History

Ask both age- and etiology-specific questions.

• Acuteness or chronicity of bleeding
• Color and quantity of the blood in stool or emesis
  • Massive UGI bleeding can produce bright red blood per rectum if GI transit time is rapid
• Antecedent symptoms
• History of straining, abdominal pain, or trauma.
• Bloody diarrhea and signs of obstruction suggest volvulus, intussusception, or necrotising enterocolitis, (ex-premature infant)
• Recurrent or forceful vomiting, Mallory-Weiss tears.
• Sudden onset of bright color hematemesis and melena of large amount Esophageal varices
• Gradual onset chronic, mild hematemesis and melena Acid peptic disease
• Acid regurgitation, nausea, vomiting, water brash, retrosternal pain Reflux oesophagitis
• H/o antepartum hemorrhage Swallowed maternal blood
• Anorexia, nausea, vomiting and epigastric pain with relation to food Peptic ulcer
• Bloody diarrhea, vomiting, abdominal pain, fever Dysentery
• History of drug intake: NSAIDS, corticosteroids, Mucosal irritants, iron preparation
• Risk factors for portal HTN- umbilical sepsis / catheterization, jaundice, liver disease Esophageal varices
• H/o Fatigue, weakness, pallor or dyspnea
• Ask questions that may reveal underlying but yet undiagnosed organ dysfunction.
• H/o
  • Bleeding diathesis
  • Medications (NSAIDs, Aspirin, warfarin, hepatotoxins)
• For complaints of bloody stool, make sure to elicit on history foods or drugs that may give a stool bloody appearance

Substances that Commonly Color Vomitus or Stools
Red

• Candies
• Red gelatin
• Beet root
• Tomato skin
• Peach skin
• Red cherries
• Phenytoin
• Rifampicin

Black

• Bismuth
• Activated charcoal
• Iron
• Spinach
• Blueberries
• Chocolate
• Grape juice
• Purple grapes

Past History

• H/o previous GI problems, Blood transfusions, Coagulopathies, Iron deficiency

Family History

• GI disorders (polyps, ulcers, colitis). In idiopathic peptic ulcer disease nearly 70% will have family history of ulcer disease.
• Liver disease
• Bleeding diathesis

Assessment of a child

• One should first determine the amount of blood loss, and the site of bleeding.
• The measurement of vital signs provides the only accurate assessment of blood loss (orthostatics, heart rate, complaints of weakness or dizziness, syncope).

Initial Evaluation

• Performed concurrently with resuscitative measures regardless of the site of bleeding.

The questions that must be addressed are

• Has the child been bleeding ?
• Has the child had bleeding of sufficient magnitude to result in actual or impending circulatory collapse?
• Is the child bleeding now?
• What actions are required?

Physical examination

• Vital signs :- PR, BP, RR, T, CRT
• Acute losses of 10-25% of blood volume cause tachycardia, narrow pulse pressure and postural hypotension.
• Earliest sign to increase is HR.
• Supine Hypotension – >20% Blood loss.
• Pallor, diaphoresis, confusion, obtundation, tachycardia, tachypnea → Shock.

• Pallor
• Icterus
• Edema
• Hydration status
• Nutritional status- hematemesis/melena in a healthy thriving child Extra hepatic portal hypertension.
• Ecchymosis, bluish nodules
• Icterus with signs of liver failure like palmar erythrema, vascular telangiectasias, ascites liver disease.
• CVS
  • Pulse rate, BP sitting & standing
  • Pulse pressure
  • Capillary filling
• Abdomen
  • Distension, shiny skin, prominent veins (caput medusae)
  • Abdominal tenderness, with or without a mass, s/o intussusception or ischemia
  • Splenomegaly, Hepatomegaly
  • Evidence of free fluid
  • Hyperactive bowel sound
• Inspection of the perianal area
  • fissures, fistulas, skin breakdown, or evidence of trauma.
  • Gentle digital rectal examination may reveal polyps, masses, or occult blood.
  • Looking for evidence of child abuse, such as perianal tearing, tags, or irregularities in anal tone and contour, is also important.
• Examination of the skin
  • evidence of systemic disorders, such as inflammatory bowel disease, Henoch-Schönlein purpura, and Peutz-Jeghers polyposis.
• Examination of the head, ears, eyes, nose, and throat
  • look for causes such as epistaxis, nasal polyps, and oropharyngeal erosions from caustics and other ingestions.
  • Color of stool
• NG aspiration
  • A positive NG tube aspirate for blood usually signifies that the site of bleeding is proximal to the ligament of Treitz.
  • Assessing the activity and severity of upper GI bleeding

Investigations

• Blood
  • CBC, coagulation profile (PT, APTT, Platelets).
  • Blood grouping and cross matching of blood.
  • BUN
• LFT and RFT
  • To stratify risk in case invasive intervention is required.
• Stool
  • Occult blood
• Apt test
  • To differentiate between maternal and fetal blood.
• Localization Studies
  • Definitive management depends upon localization of its source and underlying cause.
• Esophagogastroduodenoscopy
  • Allows prompt diagnosis and the ability to guide or perform therapy to hasten cessation of bleeding.
  • within the first 12 hours of the hemorrhagic episode if they are sufficiently stable because early endoscopy improves the diagnostic index.
  • The source of bleeding can be identified in 90% of cases if endoscopy is done within the first 24 hours.
  • Infants and children with anemia and positive stool occult-blood, even in the absence of melena, hematemesis or hematochezia, often need upper GI endoscopy examination.
  • Preferred method of Diagnosis and treatment.
• The Forress classification divides endoscopic findings into 3 categories
  • I – Active hemorrhage (Ia = bright red bleeding, Ib = slow bleeding)
  • II – Recent hemorrhage (IIa, = nonbleeding visible vessel, IIb = adherent clot on base of lesion, IIc = flat pigmented spot)
  • III – No evidence of bleeding
• Colonoscopy: For lower GI bleeds, can reveal the source of bleeding more effectively than barium enema, and it has 80% sensitivity.
  • Colonoscopy should be performed only when the patient is stable and when blood and feces will not conceal proper visualization.
  • The yield of finding a potential bleeding source in the colon is greatest if colonoscopy is performed within the initial 24 hours of presentation.
• USG abdomen
  • Suspected portal HTN.
  • For suspected intussusception, color Doppler ultrasonography can be used. Its sensitivity is 98-100%, and its specificity is 89-100%, but these rates are operator dependent.
• Tc 99m – labeled RBC scan
  • Can localize sites with bleeding rates of 0.1ml/min.
• Meckel scan uses technetium-99m pertechnetate to highlight the ectopic gastric mucosa.
• GI contrast studies
  • Contraindicated with active bleeding as the contrast can obscure endoscopic and angiographic studies.
  • To point to foreign bodies, esophagitis, inflammatory bowel disease, or polyps.
  • For neonates with malrotation with midgut volvulus, it may show a corkscrew of small bowel or a bird’s beak if complete obstruction is present
• Angiography
  • Useful if endoscopy is not definitive.
  • Allows rapid localization and potential therapy of GI bleeding, extravasation of the dye into the intestine when bleeding rates > 0.5ml/min.
  • May also delineate the anatomy of bleeding lesion.
  • Offers the possibility of Rx – e.g., embolization, vasopressin infusion.
• Nasopharyngoscopy and CT scan of PNS
  • If the source of bleeding is thought to be from sinuses or nasopharynx.
• CXR
  • To r/o causes of hemoptysis e.g cystic fibrosis, bronchiectasis
• Plain abdominal radiography:
  • Patients with suspected obstruction
  • May also be helpful in those neonates in whom necrotizing enterocolitis is a possibility;
  • the images may show free air, pneumatosis intestinalis (bubbles in the bowel wall), or portal air

Management

1. Initial Resuscitation
   • Airway protection
     • Endotracheal intubation – to prevent aspiration- considered in situations in which diminished mental status (shock, hepatic encephalopathy), massive hematemesis or active variceal hemorrhage is +nt.
   • Restoration of intravascular volume
     • Large bore IV line – esp. 2.
     • CVP should be established in overt GI bleeding.
     • NS, RL or hemaccel.
     • Blood- best for volume replacement in severe blood loss.
     • O-ve blood can be used in emergency
   • Correction of coagulopathy
     • Discontinue offending anticoagulant.
     • Fresh blood.
     • Infusion of FFP if possible.
     • Vitamin K in  PT in patients on warfarin Rx or with hepatobiliary diseases → total 3 doses.
     • Platelet infusion if < 50,000/mm3.
2. Specific management
• Peptic ulcer – barrier agents (sucralfate), H2-antagonists (cimetidine, ranitidine, famotidine), H+-pump inhibitors (omeprazole, lansoprazole).
• Coagulation – cautery, heater probe, laser.

Management of Variceal bleeding

• Fluid resuscitation- crystalloids, packed RBCs, whole blood.
• Coagulopathy- Vit K, FFP.
• H2- blocker (ranitidine) – decrease bleeding from gastric erosion.
• Pharmacologic Rx
  • To decrease portal pressure and if there is continuous bleeding.
• Vasopressin
  • Splanchnic vascular tone and ↓ portal blood flow.
  • Bolus 0.33U/Kg over 20mins, then same dose/hr infusion (or 0.2U/1.73m2/min).
  • Causes vasoconstriction.
• Nitroglycerine skin patches
  • ↓ portal pressure.
• NTG + vasopressin
  • may ameliorate some of its side effects
• Octreotide
  • ↓es splanchnic blood flow and reduces portal pressure.
• Non-selective β – blockers
  • g. Propranolol, timolol
  • Lower cardiac output (β1 blockade) and portal pressure (β2 blockade).
  • Used extensively in adults.
  • In adults – evidence shows that it ↓es the incidence of variceal hemorrhage and improve long term survival.
  • Therapeutic effect – pulse rate ↓ed by at least 25%.
• Endoscopy
  • Sclerosis
  • Elastic band ligation – safer, more effective.
• Sengstaken – Blakemore tube
  • If pharmacologic and endoscopic measures fail.
  • Mechanically compress esophageal and gastric varices.
• Endoscopy
  • Sclerosis
  • Elastic band ligation – safer, more effective.
• Sengstaken – Blakemore tube
  • If pharmacologic and endoscopic measures fail.
  • Mechanically compress esophageal and gastric varices.
• Surgery
  • Portocaval shunt – to divert portal blood flow.
• TIPSS (Transjugular intrahepatic portosystemic shunting)
  • Shunt placed between hepatic veins and the portal vein.
• Liver transplantation
  • In chronic liver diseases or post sinusoidal veno-occlusive diseases.