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 — Pediatric 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 .
- Rodgers BM. Upper gastrointestinal hemorrhage. Pediatr Rev 1999; 20:171.
- Grimaldi-Bensouda L, Abenhaim L, Michaud L, et al. Clinical features and risk factors for upper gastrointestinal bleeding in children: a case-crossover study. Eur J Clin Pharmacol 2010; 66:831.
- Cochran EB, Phelps SJ, Tolley EA, Stidham GL. Prevalence of, and risk factors for, upper gastrointestinal tract bleeding in critically ill pediatric patients. Crit Care Med 1992; 20:1519.
- Lacroix J, Nadeau D, Laberge S, et al. Frequency of upper gastrointestinal bleeding in a pediatric intensive care unit. Crit Care Med 1992; 20:35.
- López-Herce J, Dorao P, Elola P, et al. Frequency and prophylaxis of upper gastrointestinal hemorrhage in critically ill children: a prospective study comparing the efficacy of almagate, ranitidine, and sucralfate. The Gastrointestinal Hemorrhage Study Group. Crit Care Med 1992; 20:1082.
- Cox K, Ament ME. Upper gastrointestinal bleeding in children and adolescents. Pediatrics 1979; 63:408.
- Kato S, Nakagawa H, Harada Y, et al. A clinical study of upper gastrointestinal endoscopy in Japanese children. Acta Paediatr Jpn 1991; 33:36.
- Zahavi I, Arnon R, Ovadia B, et al. Upper gastrointestinal endoscopy in the pediatric patient. Isr J Med Sci 1994; 30:664.
- Yachha SK, Khanduri A, Sharma BC, Kumar M. Gastrointestinal bleeding in children. J Gastroenterol Hepatol 1996; 11:903.
- Mittal SK, Kalra KK, Aggarwal V. Diagnostic upper GI endoscopy for hemetemesis in children: experience from a pediatric gastroenterology centre in north India. Indian J Pediatr 1994; 61:651.
- Fishman SJ, Burrows PE, Leichtner AM, Mulliken JB. Gastrointestinal manifestations of vascular anomalies in childhood: varied etiologies require multiple therapeutic modalities. J Pediatr Surg 1998; 33:1163.
- Fox VL. Gastrointestinal bleeding in infancy and childhood. Gastroenterol Clin North Am 2000; 29:37.
- Borowitz SM. Ulcerative esophagitis. A rare source of upper gastrointestinal bleeding in a neonate. Use of fiberoptic endoscopy for diagnosis. Clin Pediatr (Phila) 1989; 28:89.
- O'Neil EA, Chwals WJ, O'Shea MD, Turner CS. Dexamethasone treatment during ventilator dependency: possible life threatening gastrointestinal complications. Arch Dis Child 1992; 67:10.
- Wilcox DT, Jacobson A, Bruce J. Haemorrhage from a duodenal ulcer in a neonate. Pediatr Surg Int 1997; 12:202.
- Goyal A, Treem WR, Hyams JS. Severe upper gastrointestinal bleeding in healthy full-term neonates. Am J Gastroenterol 1994; 89:613.
- Madan A, Lavine JE, Heyman MB, Townsend SF. Acute hemorrhagic gastritis in the newborn infant. J Perinatol 1992; 12:377.
- Ng PC, So KW, Fok TF, et al. Fatal haemorrhagic gastritis associated with oral sulindac treatment for patent ductus arteriosus. Acta Paediatr 1996; 85:884.
- Peiper M, Lambrecht W, Kluth D, Hüneke B. Bleeding esophageal duplication detected in utero. Ann Thorac Surg 1995; 60:1790.
- Bedu A, Faure C, Sibony O, et al. Prenatal gastrointestinal bleeding caused by esophagitis and gastritis. J Pediatr 1994; 125:465.
- Cairo MS, Grosfeld JL, Weetman RM. Gastric teratoma: unusual cause for bleeding of the upper gastrointestinal tract in the newborn. Pediatrics 1981; 67:721.
- Haley T, Dimler M, Hollier P. Gastric teratoma with gastrointestinal bleeding. J Pediatr Surg 1986; 21:949.
- Nagaya M, Kato J, Niimi N, et al. Isolated cavernous hemangioma of the stomach in a neonate. J Pediatr Surg 1998; 33:653.
- Stillman AE, Hansen RC, Hallinan V, Strobel C. Diffuse neonatal hemangiomatosis with severe gastrointestinal involvement. Favorable response to steroid therapy. Clin Pediatr (Phila) 1983; 22:589.
- Neidich GA, Cole SR. Gastrointestinal bleeding. Pediatr Rev 2014; 35:243.
- Stephen TC, Bendon RW, Nagaraj HS, Sachdeva R. Antral duplication cyst: a cause of hypergastrinemia, recurrent peptic ulceration, and hemorrhage. J Pediatr Gastroenterol Nutr 1998; 26:216.
- Saxonhouse MA, Manco-Johnson MJ. The evaluation and management of neonatal coagulation disorders. Semin Perinatol 2009; 33:52.
- Brumbaugh DE, Colson SB, Sandoval JA, et al. Management of button battery-induced hemorrhage in children. J Pediatr Gastroenterol Nutr 2011; 52:585.
- Ferri PM, Ferreira AR, Fagundes ED, et al. Portal vein thrombosis in children and adolescents: 20 years experience of a pediatric hepatology reference center. Arq Gastroenterol 2012; 49:69.
- Murray KF, Jennings RW, Fox VL. Endoscopic band ligation of a Dieulafoy lesion in the small intestine of a child. Gastrointest Endosc 1996; 44:336.
- Itani M, Alsaied T, Charafeddine L, Yazbeck N. Dieulafoy's lesion in children. J Pediatr Gastroenterol Nutr 2010; 51:672.
- Soukoulis IW, Liang MG, Fox VL, et al. Gastrointestinal Infantile Hemangioma: Presentation and Management. J Pediatr Gastroenterol Nutr 2015; 61:415.
- Sigalet DL, Laberge JM, DiLorenzo M, et al. Aortoesophageal fistula: congenital and acquired causes. J Pediatr Surg 1994; 29:1212.
- Mestre JR, Andres JM. Hereditary hemorrhagic telangiectasia causing hematemesis in an infant. J Pediatr 1982; 101:577.
- Bowles LJ, Kostopoulos-Farri E, Papageorgiou AN. Perinatal hemorrhage associated with the Kassabach-Merritt syndrome. Clin Pediatr (Phila) 1981; 20:428.
- Murty TV, Bhargava RK, Rakas FS. Gastroduodenal duplication. J Pediatr Surg 1992; 27:515.
- Hollander M, Tabingo R, Stankewick WR. Successful treatment of massive intestinal hemorrhage due to hookworm infection in a neonate. J Pediatr 1973; 82:332.
- Clark JH, Fitzgerald JF. Hemorrhagic complications of Henoch-Schönlein syndrome. J Pediatr Gastroenterol Nutr 1985; 4:311.
- Siew JX, Yap TL, Phua KB, et al. Annular pancreas: a rare cause of upper gastrointestinal bleeding in a child. J Pediatr Gastroenterol Nutr 2013; 57:e34.
- Nagpal R, Schnaufer L, Altschuler SM. Duodenal web presenting with gastrointestinal bleeding in a seven-month-old infant. J Pediatr Gastroenterol Nutr 1993; 16:90.
- Beluffi G, Luraschi D, De Giacomo C, et al. Antral web--a rare cause of vomiting and haematemesis in childhood. Australas Radiol 1985; 29:341.
- Smith TF, Welch TR, Allen JB, Sondheimer JM. Cutaneous mastocytosis with bleeding: probable heparin effect. Cutis 1987; 39:241.
- Bulstrode NW, Cuckow PM, Spitz LS. Neonatal gastrointestinal pseudohaemorrhage. J R Coll Surg Edinb 1998; 43:355.
- Rosenthal P, Thompson J, Singh M. Detection of occult blood in gastric juice. J Clin Gastroenterol 1984; 6:119.
- Mills RW, Burke S. Gastrointestinal bleeding in a 15 month old male. A presentation of Munchausen's syndrome by proxy. Clin Pediatr (Phila) 1990; 29:474.
- Thomson MA, Leton N, Belsha D. Acute upper gastrointestinal bleeding in childhood: development of the Sheffield scoring system to predict need for endoscopic therapy. J Pediatr Gastroenterol Nutr 2015; 60:632.
- Freedman SB, Stewart C, Rumantir M, Thull-Freedman JD. Predictors of clinically significant upper gastrointestinal hemorrhage among children with hematemesis. J Pediatr Gastroenterol Nutr 2012; 54:737.
- Berezin SH, Bostwick HE, Halata MS, et al. Gastrointestinal bleeding in children following ingestion of low-dose ibuprofen. J Pediatr Gastroenterol Nutr 2007; 44:506.
- Williams J, Vasanawala SS. Active gastrointestinal hemorrhage identification by blood pool contrast-enhanced magnetic resonance angiography. Pediatr Radiol 2011; 41:1198.
- Racadio JM, Agha AK, Johnson ND, Warner BW. Imaging and radiological interventional techniques for gastrointestinal bleeding in children. Semin Pediatr Surg 1999; 8:181.
- Aarts R, Ijland MM, de Blaauw I, et al. Severe gastrointestinal tract bleeding in a two-month-old infant due to congenital intrahepatic arterioportal fistula. Eur J Radiol 2006; 59:25.
- Gilbert DA, Saunders DR. Iced saline lavage does not slow bleeding from experimental canine gastric ulcers. Dig Dis Sci 1981; 26:1065.
- Lam JC, Aters S, Tobias JD. Initial experience with octreotide in the pediatric population. Am J Ther 2001; 8:409.
- Eroglu Y, Emerick KM, Whitingon PF, Alonso EM. Octreotide therapy for control of acute gastrointestinal bleeding in children. J Pediatr Gastroenterol Nutr 2004; 38:41.
- Imperiale TF, Birgisson S. Somatostatin or octreotide compared with H2 antagonists and placebo in the management of acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Ann Intern Med 1997; 127:1062.
- Shneider BL, Bosch J, de Franchis R, et al. Portal hypertension in children: expert pediatric opinion on the report of the Baveno v Consensus Workshop on Methodology of Diagnosis and Therapy in Portal Hypertension. Pediatr Transplant 2012; 16:426.
- Goenka AS, Dasilva MS, Cleghorn GJ, et al. Therapeutic upper gastrointestinal endoscopy in children: an audit of 443 procedures and literature review. J Gastroenterol Hepatol 1993; 8:44.
- Balsells F, Wyllie R, Kay M, Steffen R. Use of conscious sedation for lower and upper gastrointestinal endoscopic examinations in children, adolescents, and young adults: a twelve-year review. Gastrointest Endosc 1997; 45:375.
- Chang MH, Wang TH, Hsu JY, et al. Endoscopic examination of the upper gastrointestinal tract in infancy. Gastrointest Endosc 1983; 29:15.
- Thakkar K, El-Serag HB, Mattek N, Gilger MA. Complications of pediatric EGD: a 4-year experience in PEDS-CORI. Gastrointest Endosc 2007; 65:213.
- Mahoney LB, Lightdale JR. Sedation of the pediatric and adolescent patient for GI procedures. Curr Treat Options Gastroenterol 2007; 10:412.
- Cano I, Urruzuno P, Medina E, et al. Treatment of esophageal varices by endoscopic ligation in children. Eur J Pediatr Surg 1995; 5:299.
- Fox VL, Carr-Locke DL, Connors PJ, Leichtner AM. Endoscopic ligation of esophageal varices in children. J Pediatr Gastroenterol Nutr 1995; 20:202.
- Price MR, Sartorelli KH, Karrer FM, et al. Management of esophageal varices in children by endoscopic variceal ligation. J Pediatr Surg 1996; 31:1056.
- Sasaki T, Hasegawa T, Nakajima K, et al. Endoscopic variceal ligation in the management of gastroesophageal varices in postoperative biliary atresia. J Pediatr Surg 1998; 33:1628.
- Infants, children and adolescents
- Differential diagnosis
- CLINICAL PRESENTATION
- CLINICAL ASSESSMENT
- Initial assessment and resuscitation
- Physical examination
- Laboratory evaluation
- Other diagnostic tests
- Nasogastric tube
- Pharmacologic options
- - Acid suppression
- - Somatostatin and octreotide
- SUMMARY AND RECOMMENDATIONS