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16 year old

male

1 day history of black stools and bright red bloody emesis

Initial hemoglobin 9.4 pRBC transfusion Administered PPI Yes NG - In place upon arrival

PICU X4 days + floor 6 days Shock-AKI with large volume resuscitation (pRBC, plts and cryo)

EGD - several varices and 1 gastric varix + mild portal HTN

Upper GI BleedsMedical Video Review

Learning Objectives Etiology and recognition of the upper GI tract as the source of bleeding

Management of Upper GI bleeding with hemorrhagic shock in the STS

16 year old

male

17 year old

male

4 year old female

15 year old

male

17 year old

male

A few hours of nausea and dark coffee colored emesis

Initial hemoglobin 10.2 pRBC transfusion Administered PPI Yes NG - No

PICU x 3 days + floor 7 days Shock, intubation and continued hematemesis, epi drip

EGD - large esophageal and gastric varices with large clot in obstructing part of the gastric wall

16 year old

male

17 year old

male

4 year old female

15 year old

male

4 year old female

Dark stool for 1 day and coffee ground emesis

Initial hemoglobin 7 pRBC transfusion Administered PPI yes NG - No

Floor x 7 days, Abd U/S: Cavernous transformation of the portal vein, Cirrhosis, splenomegaly, enlarged gall bladder and ascites Hep C AB+, Hep A IgG+, Hep Bs+

EGD - Esophageal varices with banding

16 year old

male

17 year old

male

4 year old female

15 year old

male

15 year old

male

1.5 weeks of melena and 1 day of coffee ground emesis, syncope

Initial hemoglobin 3.9 pRBC transfusion Administered PPI yes NG - In place upon arrival

Floor x 24 hours

EGD - multiple gastric ulcers

Etiology and recognition of the upper GI tract as the source of bleeding

Severe UGI bleeds are rare

We saw 8 in the STS in the past year

20% of GI bleeds in pediatric patients are upper

Cochran, Crit Care Med ,1992

Prospective cohort of 208 ICU patients

25% had upper GI bleeding

No association between upper GI bleeding and age, weight, race, or sex

Independent association w/ circulatory shock, an operative procedure and trauma

Lacroix, Crit Care Med,1992

Prospective study of >900 patients

<7% UGI bleed

Multivariate analysi

Risk factors high Pediatric Risk of Mortality score, coagulopathy, pneumonia, and multitrauma

Pant, Curr Med Res Opin, 2014

23,383 pediatric discharges with a diagnosis of GI bleeding (0.5%)

More likely to be male (54.5% vs. 45.8%)

Older (children ≥11 years; 50.8% vs. 38.7%)

Lower GI bleeding more common (17.6 per 10,000 discharges) followed by hematemesis (11.2 per 10,000 discharges)

Highest mortality rates w/ GI bleeding intestinal (8.7%) and esophageal perforation (8.4%)

Unsurprisingly most patients with hematemesis are not seen in the bay

The most common cause of serious UGI bleeds in children >2 is a variceal bleed

Neonates

Swallowed maternal blood

Vitamin K deficient bleeding (Hemorrhagic disease of the newborn)

Stress gastritis or ulcers in shock/critical illness

NEC

Intestinal duplications or vascular anomalies

Coagulopathy

Milk protein intolerance (lower GI bleeding is more common)

Mallory-Weiss tear

Ulcers and gastritis - NSAIDs

Esophagitis

GERD is #1 in this age range, recurrent emesis, or caustic ingestion/foreign body

Variceal bleeding

More likely in children with portal hypertension

Hemangioma, Vascular malformation, HHT, Kasabach-Merritt syndrome

AV fistula

Infants/Toddlers

Mallory-Weiss tears

Peptic ulcers and gastritis

Pill esophagitis

Varices (#1 cause of severe UGI bleeding in children)

Older Children

IVC

Hepatic ve

ins

Portal vein

Esophageal vein

Gastric

vein

Intrahepatic Cirrhosis

Biliary atresia Cystic fibrosis TPN-induced liver disease

Intrahepatic scarring1

Portal vein resistance2

Pressure increase3

Portal Hypertension

Direct injuryOmphalitis Umbilical catheterization Neonatal peritonitis Abdominal trauma Cysts and tumors at the porta hepatis

Portal vein abnormalitiesStenosis/atresia/agenesis

Indirect factorsSepsis Dehydration Multiple exchange transfusions Hypercoagulable states

IVC

Hepatic ve

ins

Portal vein

Esophageal vein

Gastric

vein

Prehepatic Portal vein thrombosis or narrowing

Portal vein obstruction1

Splenomegaly + thrombocytopenia2

Portal Hypertension

IVC

Hepatic ve

ins

Portal vein

Esophageal vein

Gastric

vein

Suprahepatic Post-sinusoidal portal hypertension

Budd Chiari CHF Veno-occlusive disease

Suprahepatic resistance1

Pressure increase2

Portal Hypertension

Peptic ulcer (35-50%)

Esophagitis (20-30%)

Duodenitis/gastritis/erosions (10-20%)

Varices (5-12%)

Mallory-Weiss tears (2-5%)

Tumour (2-5%)

Angiodysplasia (2-3%)

Aorto-enteric fistula (<1%)

Adults

Not the GI tract Epistaxis is far and away #1

Pulmonary hemorrhage

Friable tonsils, hemorrhagic pharyngitis

Injury

Post T&A bleeding

Not actually blood Red food (drinks, candy, beets)

Hint: do a guaiac test

Management of Upper GI bleeding with hemorrhagic shock in the STS

ABCs (Recognition of shock state)

Access x2

Determination of hemoglobin early

Anticipate need for blood

Focused history

NSAID use

Family history of H. pylori

Relevant comorbidities (including psych re caustic ingestion)

Pain

Fever

Diarrhea

Previous hemoglobin

Blood Products

O Negative Blood was given emergently in STS 12 times over the past year (medical and trauma)

To obtain blood emergently for medical patients: Call 636-4508 Name, gender and MRN Number of units Send a transporter

Blood Products

Type & Cross

When potential for blood transfusion need is high

ABO/Rh blood type and antibody screen

In the crossmatch, the patient's blood and donor blood are tested for compatibility

Turn around time is approx. 35-45 min once blood arrives in the lab

Type and screen

ABO/Rh blood type is determined, and an antibody screen is done

No blood is crossmatched

Blood Products

One unit of blood is 280-320 mL (average 300mL)

Blood is good for 4 hours once the bag is spiked

You may want to consider premedication with Tylenol and Benadryl

Blood Products

Consent for blood is not covered under the general ED consent for treatment

Under emergent conditions consent for blood must be obtained within 24 hours

Includes O- not just type specific

Usually obtained by the admitting service

Under less emergent conditions obtain consent upon ordering blood

Hard copies located in “STS Forms” binder on WOW or on Centerlink

Blood Products

Alaris

Can not warmed (consider hot line )

Two Units can be given before filter change

Use a Large Standard Blood filter 170-260 micron, then attach Alaris tubing.

Belmont

Gives rapidly and warms – no special filters needed

Filter does not need to be changed, can give approx. 70 units

Push/pull

Use with the hotline to warm blood

FFPpRBC Platelets

Shock +/- Acute ↓ Hb ≤ 7.0 INR >1.5 <50 x 109/L

Blood Products

Medical Management

Proton Pump Inhibitor In adults 80 mg IV loading dose and 8 mg/hr for 72 hours Reduces high-risk stigmata and need for endoscopic therapy if given pre-endoscopy (OR 0.67) Reduces risk of rebleeding, surgery and death in high-risk patients if given after endoscopy (RR 0.4 / 0.43 / 0.41 respectively)

H2 blocker Cheap + safe but poor ability to consistently maintain a high intragastric pH >6 No evidence for effect in acute bleeding

Octreotide Somatostatin analog that reduces portal venous inflow and intravariceal pressure

Considered if the patient is unstable due to volume loss and there is going to be some delay in getting to the PICU or OR

Reduce the risk of rebleeding in adult patients with variceal hemorrhage

Also may reduce the risk of bleeding due to nonvariceal causes

Initial bolus of 1 µg/kg (max 100 µg), followed by 1 µg/kg/hr continuous IV infusion

Medical Management

Vasopressin/Terlipressin Used in a similar fashion to octreotide

Beta Blockers In adults reduces risk of recurrent variceal bleedTitrate to 25% of resting HR reduction

Prokinetics (Erythromycin, Metclopramide)May improve visualization if given prior to endoscopy

Tranxemic Acidantifibrinolytic, may reduce mortality

AntibioticsIn adults with cirrhosis 20% have infections upon presentation with UGI50% develop one while hospitalized

Medical Management

Patients with airway compromise

Ongoing bleeding

Large bore tube for suctioning and decompression

NGTube

Per Fleisher

“All patients with a significant bleeding episode should have a nasogastric tube

placed for a diagnostic saline lavage”

Clinically significant = more than a teaspoon EBL

NG/OG lavage to confirm if ongoing bleeding

NGTube

If the lavage returns fresh blood or coffee grounds UGI or nasopharyngeal bleed

Red flecks or coffee grounds – LOW rate of bleeding

Bright red blood – FAST rate of bleeding

Lavage may not be positive if the bleeding has ceased or arises beyond a closed pylorus

Bilious fluid + no blood pylorus is open and no active UGI bleeding

NGTube

Specific technique of Saline lavage

Volume of saline

50 mL infants

100-200 mL older children

You really don’t need to perform lavage for greater than 10 min

Afterwards leave the tube to low wall suction

NGTube

Ice water lavage (an older practice) does not slow bleeding & may induce iatrogenic hypothermia

Do you think that we should perform saline lavage on upper GI bleeds?

NGTube

Recommendations from GI Faculty

NG recommended on a per-patient basis, not everyone

The result of gastric lavage doesn’t dissuade them from EGD when the blood has only been present as melena

Neurologically compromised + vomiting should get a large NG for suctioning/decompression of the stomach to limit potential for aspiration

28-36 French tube to evacuate

10-16 French salem sumps get clogged

Hard to gauge rate of bleeding

Diagnostic modality of choice for UGI bleeding

Determines source of bleeding for 90%

Goal within 24-48 of severe/acute bleeds

Safe in children

Endoscopy

Source Identification

RiskStratification

Therapeutic Intervention

Technique is lesion dependent

Diffuse mucosal disease = medical management

Focal source (ulcer, visible vessel)

Focal coagulation

Tamponade vessel (clip or band)

Endoscopy

The therapy applied depends on being able to find, see, and approach the lesion, the size of

the lesion and the size of the child - which determines which scope will fit and which

instruments will go through it.

Immediate control of hemorrhage with injection of epinephrine followed by a

coagulative or tamponading intervention (in adults, at least) limits the potential for rebleeding under most circumstances.

- Philip Putnam, Gastroenterology

Endoscopy

Balloon tamponade with a Sengstaken-Blakemore or Minnesota tube is 80% successful but has a higher rate of rebleeding and pressure necrosis

Sclerotherapy with sodium morrhuate is 90-95% successful and is often repeated q2-4 weeks

Variceal banding is comparable to sclerotherapy but is more difficult to perform in children because of the smaller esophagus

Endoscopy

When conservative management fails (multiple transfusions + meds + endoscopy) surgery is indicated

TIPS for intrahepatic portal hypertension to provide temporary decompression of the intrahepatic portal vein into the hepatic veins

Surgical portosystemic or portoportal shunts for refractory cases and/when liver transplantation is not an option

Sugiura procedure is rarely performed - removal of vessels of upper stomach and esophagus + splenectomy

Other studies

If endoscopy fails to identify bleeding source = arteriography

Can detect bleeding at a rate of 0.5 mL/min per minute

Allows for embolization and and intra-arterial administration of vasoconstrictors

Take Home Points

Most serious bleeds are variceal

NG Lavage is generally not necessary

Administer IV PPI early

Endoscopy is safe and effective

The End