ERA’S JOURNAL OF MEDICAL RESEARCH
UPPER GASTROINTESTINAL BLEEDING IN CHILDREN
Department of Pediatrics
Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh India– 226003.
Upper gastrointestinal bleeding (UGIB) is a life
Address for correspondence
threatening condition in children. Bleeding may occur
anywhere along the gastrointestinal tract. Children who
Department of Pediatrics
present with hematemesis constitute 10–15% of referrals
Era's Lucknow Medical College & Hospital,
to pediatric gastroenterologists (Arain and Rossi 1999).
Sarfarazganj, Hardoi Road, Lucknow –226003
Gastrointestinal bleeding can be roughly divided into
Phone no– 9918208555
three clinical syndromes (1).
a. Upper gastrointestinal bleeding: UGIB is from a
source between the pharynx and the ligament of Trietz.
This type of bleeding is characterised by hematemesis
What is the site of bleeding? Melena is indicative of a
significant blood loss (over 2% of blood volume) most
likely taking place distal to the ligament of Trietz.
b. Lower gastrointestinal bleeding: Lower
Lesions proximal to the ligament of Trietz presents
gastrointestinal bleeding may be indicated by red blood
usually as vomiting of bright red or coffee ground blood.
per rectum, especially in the absence of hematemesis.
Isolated melena may originate from anywhere between
How much blood has been lost? If bleeding is slow, as much
the stomach and the proximal colon.
as 13% of blood can be lost without any hemodynamic
change. The loss of palmer crease erythema may be seen
c. Bleeding from obscure sources: Defined as
when the hand is hyperextended as a sign of 50% or
bleeding of unknown origin that persists or recurs, that is
more blood volume loss(Arain and Rossi 1999) (3).
recurrent or persistent iron deficiency anemia, occult
blood test positivity, or visible bleeding, after a negative
initial or primary endoscopy (colonoscopy and/or upper
Microscopic blood loss in the stool can be
endoscopy) result(Roy and Ozden 2003)
confirmed with a faecal occult blood test. For
Four questions need to be answered by taking history and
upper GI bleeding, a nasogastric tube is placed to
physical examination(Arora, Mathur et al. 2004).
confirm the presence of fresh blood and to evaluate
Therefore a complete and thorough history and physical
the degree of active bleeding.
examination is vital (2).
Is it actually blood? A number of substances such as
(EGD) and colonoscopy are currently considered
food coloring agents, vegetables such as beetroot,
the first–line diagnostic procedures. The site and
drugs like ampicillin and phenobarbital may mimic
the cause of bleeding can be identified in 85 to 90%
hematochezia. Newborns who have swallowed maternal
of the patients(Prolla, Diehl et al. 1983).
blood can present with significant melena or
hematemesis while appearing stable clinically. The Apt
Radionuclide studies: (99m)Tc–labeled
Downey test performed on the emesis identifies the
erythrocytes and (99m)Tc sulfur colloid are 2
source of bleeding (Apt and Downey 1955) Is the child
commonly used techniques to detect active
actually bleeding from the gastrointestinal tract? There
bleeding. It has a false localization rate of
are certain situations in which the source of the blood
approximately 22%, which limits its value as a
might not be the gastrointestinal tract, but can actually
diagnostic test(Fallah, Prakash et al. 2000). The
come from the respiratory tract, oropharyngeal region,
diagnostic sensitivity of the scans in a
nose and nasopharyngeal area. There might be coexisting
retrospective study was 39.1%(Lee, Lai et al.
conditions like bleeding diathesis or malignancy that
may predispose the child to mucosal bleeding.
114 UPPER GASTROINTESTINAL BLEEDING IN CHILDREN
Newborns Infants One year to 12 years
Swallowed maternal bloodGastritis Esophageal varices
Hemorrhagic disease of the newbornEsophagitis Peptic ulcer disease
Gastritis Stress ulcers Gastritis
Vascular malformationsMallory Weiss tears
of gastritis, peptic ulcers and superficial mucosal
Conventional angiography: It is particularly
useful in the evaluation of difficult to diagnose
cases of recurrent UGI bleeding (Cox and Ament
Proton pump inhibitors: Targeting the terminal
1979). An accurate angiographic diagnosis is more
step in acid production, as well as the irreversible
likely in acute GI bleeding than in chronic GI
nature of the inhibition, results in their ability to
bleeding, (71% vs. 55%) (Arora, Mathur et al.
reduce gastric acid secretion by up to 99%.
Sucralfate: It is a sucrose sulfate–aluminum
CT angiography: CT angiography is an excellent
complex which serves as protective barrier at the
tool for fast and accurate diagnosis and localization
ulcer surface, preventing further damage from acid,
of acute GI bleeding.
pepsin, and bile (6).
Capsule endoscopy: A promising new technology
introduced to clinical practice in gastroenterology
Endoscopic management of mucosal bleeding
is capsule endoscopy. The capsule is suitable for
A meta–analysis on the role of injection therapies
cases of obscure bleeding from the mouth to the
for bleeding ulcers has found no difference between
colon. It can successfully image small bowel
various techniques like thermal therapy, sclerosant
pathologic features throughout the GI tract.
therapy, clips, and thrombin/fibrin glue(Laine and
Although this technology cannot be used for biopsy
McQuaid 2009) (9).
or therapy, it may prove valuable in the assessment
of bleeding with negative results on gastroscopy
Pharmacologic management of variceal
and colonoscopy (4).
Start all patients on H2 receptor blocker drugs or
Management of gastrointestinal bleeding
Proton pump inhibitors. A vasoactive drug should
The goals of therapy in a child with UGIB are
also be started to decrease the splanchnic pressures.
hemodynamic resuscitation, cessation of bleeding
There is very little to choose between octreotide
source and prevention of future episodes of GI
and somatostatin except that the latter is costlier (8).
Pharmacologic management of mucosal
Endoscopy should be performed when the patient has
been stabilized and preferably within 24 hours of
Therapy in these groups of patients is directed at
admission or onset of hemorrhage(Cox and Ament
neutralizing and/or preventing the release of acid.
1979). The modalities available for controlling acute
The various agents used include:
variceal bleeding are either variceal ligation or
Antacids: In children more than five years of age,
sclerotherapy. Sclerotherapy can control acute variceal
magnesium and aluminum hydroxide in doses of
bleeding in 70–100% of cases. However, in a meta–
analysis endoscopic variceal ligation therapy
the 30ml/hr for the first 48 hours followed by same
significantly reduced rebleeding, mortality, frequency
dose at one and three hours after meals throughout
of esophageal strictures and the number of sessions
the remainder of hospitalization.
required to achieve variceal eradication when compared
H2 receptor antagonists: are used in the treatment
with injection sclerotherapy (Laine and Cook 1995) (9).
115 VOL.2 NO.2
ERA’S JOURNAL OF MEDICAL RESEARCH
Pharmacologic Therapy of Gastrointestinal Bleeding (8)
RanitidineControl of active bleed and
Continuous infusion, 1 mg/kg followed by
prevention of rebleeds
infusion of 2 to 4 mg/kg per day
Bolus infusions, 3 to 5 mg/kg per day
PantoprazoleControl of active bleed
Children <40 kg: 0.5 to 1 mg/kg per day IV
Children >40 kg: 20 to 40 mg once daily
OctreotideControl of active bleed
1 mcg/kg IV bolus (maximum, 50 mcg)
followed by 1 mcg/kg per hour
May increase infusion rate every 8 hours to 4
mcg/kg per hour (maximum, 250 mcg per 8
SomatostatinControl of active bleed
250 g IV bolus followed by 250 g/hour
Can be maintained from 2–5 days, if
Monitor for hyperglycaemia every 6 hourly
Side effects: abdominal discomfort, flushing,
nausea, bradycardia, steatorrhoea, dyspepsia
Glypressin (Terlipressin)Control of active bleed
2 mg IV every 4 hours till a bleeding free
interval of 24 – 48 hours is achieved
Side effects same as somatostatin
VasopressinControl of active bleed0.002 to 0.005 units/kg per minute X 12
hours, then taper over 24 to 48 hours
SucralfateCoating of ulcerated mucosa40 to 80 mg/kg per day in 4 divided doses
(maximum, 1,000 mg/dose in 4 divided
Propranololprevention of rebleeds1 mg/kg per day in 2 to 4 divided doses May
increase every 3 to 7 days to maximum of 8
116 UPPER GASTROINTESTINAL BLEEDING IN CHILDREN
2. Arain, Z. and T. M. Rossi"Gastrointestinal bleeding
in children: an overview of conditions requiring
In cases where conservative management fails with
nonoperative management." Semin Pediatr Surg
combined pharmacotherapy and endoscopic
treatments, shunt and nonshunt surgeries are the
Arora, N. K., P. Mathur, et al.Upper Gastrointestinal
definitive treatment. For intrahepatic portal
Bleeding. Principles of Pediatric & Neonatal
hypertension, transjugular intrahepatic portosystemic
Emergencies. H. P. S. Sachdev, P. Choudhury, A.
shunting (TIPS) provides temporary decompression
Baggaet al. New Delhi, Jaypee Brothers Medical
of the intrahepatic portal vein into the hepatic veins.
Publishers (P) Ltd, 2004:245–256.
Surgical portosystemic or portoportal shunts for GI
Boyle, J. T."Gastrointestinal bleeding in infants and
bleeding are now reserved for refractory cases and/or
children." Pediatr Rev ,2008:29(2): 39–52.
liver transplantation is not an option (10).
Cox, K. and M. Ament "Upper gastrointestinal
bleeding in children and adolescents." Pediatrics,
Prognostic factors associated with increased
mortality(Cox and Ament 1979) (11)
Fallah, M. A., C. Prakash, et al."Acute
gastrointestinal bleeding." Med Clin North Am,
Laine, L. and D. Cook"Endoscopic ligation
compared with sclerotherapy for treatment of
esophageal variceal bleeding. A meta–analysis." Ann
Intern Med, 1995:123(4): 280–287.
Laine, L. and K. R. McQuaid"Endoscopic therapy for
bleeding ulcers: an evidence–based approach based
on meta–analyses of randomized controlled trials."
Clin Gastroenterol Hepatol, 2009:7(1): 33–47.
Lee, J., M. W. Lai, et al."Red blood cell scintigraphy
in children with acute massive gastrointestinal
CONFLICT OF INTEREST
bleeding." Pediatr Int, 2008:50(2): 199–203.
The authors declare that they have no competing
Prolla, J. C., A. S. Diehl, et al."Upper gastrointestinal
fiberoptic endoscopy in pediatric patients."
Gastrointest Endosc,1983:29(4): 279–281.
1. Apt, L. and W. S. Downey, Jr. "Melena neonatorum:
1. Roy, H. K. and N. Ozden Obscure Causes of Upper
the swallowed blood syndrome; a simple test for the
Gastrointestinal Bleeding. Acute gastrointestinal
differentiation of adult and fetal hemoglobin in
bleeding : diagnosis and treatment. K. E. Kim.
bloody stools." J Pediatr, 1955:47(1): 6–12.
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