Approach to upper gastrointestinal bleeding in children
- Xavier Villa, MD
Xavier Villa, MD
- Associate Professor of Pediatric Critical Care Medicine
- University of Texas Medical Branch
- Section Editors
- Melvin B Heyman, MD, MPH
Melvin B Heyman, MD, MPH
- Section Editor — Gastroenterology
- Professor of Pediatrics
- University of California, San Francisco
- Stephen J Teach, MD, MPH
Stephen J Teach, MD, MPH
- Section Editor — Pediatric Signs and Symptoms
- Professor of Pediatrics and Emergency Medicine
- George Washington University School of Medicine and Health Sciences
Upper gastrointestinal (UGI) bleeding (arising proximal to the ligament of Treitz in the distal duodenum) commonly presents with hematemesis (vomiting of red blood or coffee ground-like material) and/or melena (black, tarry stools). In comparison, hematochezia (bright red or maroon-colored blood or fresh clots per rectum) is usually a sign of a lower gastrointestinal (LGI) source (defined as distal to the ligament of Treitz).
The initial approach to a child with suspected UGI bleeding is discussed in this topic review. The approach to LGI bleeding in children, or to UGI bleeding in adults, is reviewed separately. (See "Lower gastrointestinal bleeding in children: Causes and diagnostic approach" and "Approach to acute upper gastrointestinal bleeding in adults".)
The incidence of UGI bleeding is not well-established in children. As much as 20 percent of all episodes of gastrointestinal (GI) bleeding in children come from an UGI source . A population-based study from France estimated that UGI bleeding occurred in 1 to 2 per 10,000 children per year (77 percent of whom required hospitalization), and that exposure to nonsteroidal antiinflammatory drugs (NSAIDs) played a role in 36 percent of these cases .
The most detailed studies have been in the critical care setting [3-5]. In one of the largest prospective studies, UGI bleeding (defined for this study as hematemesis or any amount of blood from the nasogastric tube) was observed in 63 of 984 (6.4 percent) pediatric intensive care unit (ICU) admissions . Independent risk factors for bleeding included a high Pediatric Risk Mortality score, coagulopathy, pneumonia, and multiple trauma. Higher rates of bleeding (up to 25 percent) were observed in two other series of critically ill pediatric patients who were not receiving prophylactic therapy to prevent UGI bleeding [3,5].
The most common causes of UGI bleeding in children vary depending upon age and the geographic setting. In Western countries, the most common causes are gastric and duodenal ulcers, esophagitis, gastritis, and varices [6-8]. In India and some other parts of the world, variceal bleeding predominates [9,10]. These observations may reflect regional differences in indications for endoscopy, in addition to differences in predisposing conditions. Conditions associated with structural abnormalities of blood vessels (such as hereditary hemorrhagic telangiectasia and Ehlers-Danlos syndrome) and congenital or acquired coagulopathies can produce bleeding at any time of life .
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- Infants, children and adolescents
- Differential diagnosis
- CLINICAL PRESENTATION
- CLINICAL ASSESSMENT
- Initial assessment and resuscitation
- Physical examination
- Laboratory evaluation
- Nasogastric tube
- Pharmacologic options
- - Acid suppression
- - Somatostatin and octreotide
- Other diagnostic tests
- SUMMARY AND RECOMMENDATIONS