1. A 32 month old male presented with a 2 day history of abdominal pain, black stools, and fresh blood in stool. Physical exam showed pallor and splenomegaly. 2. Initial workup revealed anemia and thrombocytopenia. Further imaging found portal cavernoma and esophageal varices, indicating extrahepatic portal vein obstruction. 3. The patient was stabilized and treated for upper gastrointestinal bleeding from esophageal varices caused by extrahepatic portal vein obstruction, the most common cause of variceal bleeding in older children in India. Endoscopy is the gold standard for diagnosis and management of upper GI bleeding.

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 mother’s 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, Meckel’s 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