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UPPER GASTROINTESTINAL
BLEEDING & PORTAL HYPERTENSION IN
CHILDREN
MANIFESTATIONS OF GI BLEED
Melaena – the passage of black, tarry stools indicates likely UGI bleed (proximal to the
ligament of Treitz)
Haematemesis – vomitus containing frank blood or brown-black “coffee grounds”
Haematochezia – passage of bright or dark red blood per rectum
In general, the redder the blood, the more distal the site of bleeding
SPURIOUS GI BLEED
Red: beets, laxatives, phenytoin, rifampin
Black: bismuth, activated charcoal, iron, spinach, blueberry, licorice
GUAIAC TEST
ETIOLOGY
ETIOLOGY
ETIOLOGY
“plucked chicken appearance”
HISTORY Drugs Retching or vomiting Jaundice Procedures Recurrent abdominal pain Bleeding disorders in family Odynophagia
EXAMINATION Stigmata of chronic liver disease
General condition
External vascular malformation
Hyperpigmented lips
Dilated abdominal wall veins, Splenomegaly
NASO GASTRIC LAVAGE Removes blood from stomach –
facilitates easier endoscopy
Confirmation of bleed/ongoing blood loss
Prevents development of encephalopathy in cirrhotic patients
ASSESSMENT OF BLOOD LOSS Disproportionate tachycardia
“Tilt” test
Capillary refill time
Signs of shock
THERAPY
PORTAL HYPERTENSION
CIRRHOSIS - PATHOLOGY
EXTRAHEPATIC PORTAL HYPERTENSION Portal vein agenesis, atresia, stenosis
Portal vein thrombosis or cavernous
transformation
Splenic vein thrombosis
Arteriovenous fistula
VASOPRESSIN Acts by increasing splanchnic vascular tone
0.3 units per kg per hour after a bolus of 0.3 U/kg over 20 min
The addition of nitroglycerin (skin patch) decreases the systemic .effects of vasopressin
Terlipressin-longer duration of action and lesser cardiac side effects
SOMATOSTATIN & ANALOGUES much better side-effect profile and
similar efficacy
3 to 5 μg per kg per hour
Octreotide has a longer half-life- bolus (2 μg/kg) followed by continuous infusion (1 to 5 μg per kg per hour)
OTHER DRUGS antibiotic prophylaxis directed at
intestinal flora (third-generation cephalosporin) should be started from admission
H2 receptor blocker or proton pump inhibitor intravenously
ENDOSCOPIC SCLEROTHERAPY (EST) Acts by producing intimitis
Injected either intra- or paravariceal
Intravariceal cyanoacrylate or histacryl glue and thrombin for gastric varices
Complications of EST include ulceration, pain, perforation, and bacteremia.
ENDOSCOPIC VARICEAL LIGATION (EVL) Draws a visible varix into the lumen of
the ligator and a band is placed around the varix
EVL is just as effective as EST but was associated with fewer complications and faster obliteration of varices.
BALLOON TAMPONADE
TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPSS)
TIPSS Indications: Recurrent variceal hemorrhage Refractory ascites Hepatorenal syndrome
Contraindications Polycystic liver disease Right heart failure Systemic infection Portal vein thrombosis Severe hepatic encephalopathy
PROPHYLAXIS Primary prophylaxis - propranolol
Secondary prophylaxis – EVL/EST
Surgical treatment: Patients with EHPVO bleeding gastric or other nonesophageal
varices severe hypersplenism
SURGICAL TREATMENT OPTIONS Decompressive shunts Devascularization Liver transplantation
THANK YOU!!!