2. Epidemiology
• GI bleeding – one of the commonest emergencies in pediatrics
• Account for 10%-20% of referrals to pediatric gastroenterologists.
• 6.4% of PICU admissions of which 0.4% is life threatening (Lacroix)
• Mortality : 4 – 9% in best centers
3. Presentation of GI Bleeding
Term Definition
Hemetemesis • Vomiting of blood – bright red/ coffee brown , small or large , with /without
clots.
• Indicates upper GI bleeding
Melena • Black tarry stools, shiny, sticky or foul smelling ( > 60 ml, stays for > 6 hrs)
• Suggests bleeding proximal to the ileocecal valve
Hematochezia • Passage of bright red/ maroon blood per rectum
• Indicates colonic source or massive upper GI bleeding
Occult blood • No obvious bleeding , slow continuous oozing
• Demonstrated by lab exam
Hematobilia • Bleeding into small intestine from biliary tract
4. Classification of GI Bleeds
Upper GI
• Esophagus
• Stomach
• Proximal
duodenum
Lower GI
• Distal to
duodeno-
jejunal
junction
9. The Forrest Classification of Upper GI Bleeds
Endoscopic findings into the following 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.
14. Diagnostic workup
It is done only after initial stabilization of the child
Step 1…. documentation of bleeding (Is it really blood?)
Step 2…. assessment of severity
Step 3…. establishing the clinical setting of bleeding
Step 4…. identification of specific site
15. Step 1: Is it really blood??
Red vomitus Black stools
• Red food color agents
• Fruit juices like tomato,
watermelon
• Antibiotic syrups, laxatives,
phenytoin, rifampin
• candy, fruit punch, Jell-o, beets
• Iron
• Chocolate
• Bismuth
• Activated charcoal, spinach,
• Blueberries,
• Licorice
16. Step 2: Assessment of severity
• Parental estimate of volume of blood in terms of
drops /spoon/ cup/ glass
• Bright red colour means rapid rate of bleeding
• Melena indicates 60-100 ml blood loss
• Hemetemesis and melena together indicate massive
blood loss
• Clinical assessment
• Sick, Pallor, pulse, BP
17. Step 2: Assessment of severity
Vital sign Blood Loss % Interpretation
Resting hypotension
(Shock)
20-25% Massive
Postural hypotension 10 -12 % Moderate
Normal < 10 % Minor
18. Step 3: Establishing the clinical setting of
bleeding
History:
- Drug ingestion (NSAID)
- Child in ICU setting – Stress ulcer
- Pain abdomen preceding the h/o bleeding - Gastritis
- Preceding h/o vomiting & retching - Mallory Weiss
- Present/past history suggestive of liver disease – Variceal bleed
19. Step 4: Establishing the site of bleeding
Physical examination
- Cutaneous stigmata of CLD
- Bleeding from other sites (muco-cutaneous). - Bleeding diathesis
- Cutaneous hemangioma - Malformations
- Splenomegaly (95% PHT vs 5% non-PHT) – Liver disease
- Liver: s/o CLD
- Ascites – Portal hypertension
20. Investigations for upper GI bleed
• Lab studies
• leucopenia, thrombocytopenia, abnormal liver enzymes, bilirubin and
albumin
• USG abdomen
• for portal hypertension
• Doppler USG
• accurate portal and venous blood flow, obstruction
• CT scan
• better delineate the portal vein and liver parenchyma change
• Upper GI Endoscopy
• Radionuclide study
• non invasive method of determining site
21. Apt Downy Test in Neonates
• Purpose:
• To differentiate between maternal and fetal blood.
• Procedure:
• The blood is placed in a test tube; sterile water is added to hemolyze the RBCs,
yielding free hemoglobin. This solution then is mixed with 1% sodium hydroxide.
• Interpretation:
• If the solution turns yellow-brown, the hemoglobin is maternal or adult
hemoglobin, which is less stable than fetal hemoglobin.
• If the solution remains the same color, it is the more stable fetal hemoglobin;
therefore, the newborn is the source of the bleeding.