Paediatric Acute care Guidelines PMH Emergency Department

 

Gastrointestinal bleeding in children is a relatively common presentation to emergency departments.

This guideline looks at upper GIT causes of bleeding. Please refer to Gastrointestinal Bleeding – Lower GIT for lower GIT causes.

Background

  • Most causes of upper GIT bleeding in children are self limiting conditions
  • In the rare event of a life threatening upper GIT bleed, urgent IV access (large bore) and resuscitation is paramount (see Serious Illness)
  • Small, self limiting GIT bleeds rarely need extensive investigation

General

Upper GIT bleeding typically presents with:

  • Haematemesis – frank blood or coffee ground
  • Malaena

Assessment

Haemodynamically unstable, shocked or persistent large bleeding

  • Pallor, tachycardia, delayed perfusion, hypotension 
    • Large bore IV access x2
    • Fluid resuscitation 20ml/kg 0.9% saline (repeat as necessary)
    • +/- Blood transfusion 
    • Early senior clinician input

Haemodynamically Stable Patients

  • Consider non GIT causes of blood
    • Swallowed blood – maternal (breastfed infants), epistaxis, oral/dental injury, haemoptysis
    • Food which can mimic blood – tomato, food colouring, beetroot
  • Thorough history will help determine the source of bleeding

History

Important points to ask in history:

  • Neonates – was vitamin K given at birth?
  • Non Steroidal Anti Inflammatory Drug use
  • Ingestion – button battery, caustic chemicals
  • Chronic liver disease
  • Cystic Fibrosis
  • Family history of bleeding disorders, inflammatory bowel disease, peptic ulcer disease

Differential Diagnoses

Diagnosis History
Swallowed blood

Maternal blood, epistaxis, post oral / dental procedures

Mallory Weiss Tear

Forceful vomiting

Oesophagitis

Reflux symptoms

Gastritis

Epigastric pain, NSAID use, Helicobacter pylori

Mucosal injury

Ingestion – button battery, caustic chemical

Oesophageal varices

Chronic liver disease, portal hypertension

Vascular malformation

Uncommon – may be cutaneous vascular malformations

Investigations

  • Minor self limiting upper GI bleeds rarely require investigation and parental reassurance is all that is necessary.
  • Investigation of significant upper GI bleeds should be guided by suspected underlying cause.

Lab tests:

  • Full blood count
  • Coagulation profile
  • Group and hold or cross match
  • Liver function tests
  • APT-Downey test – differentiates adult haemoglobin (swallowed maternal blood) from foetal haemoglobin 

Endoscopy

  • Significant upper GI bleeds and mucosal injury should be referred to gastroenterology for endoscopy
  • Urgent gastroenterology referral is required for patients with:
    • Haemodynamic instability
    • Active bleeding
    • Oesophageal varices
    • Button battery in oesophagus

Management

Significant Bleeding
  • Large bore IV access x2
  • Fluid resuscitation +/- blood transfusion as necessary
  • Correct any clotting abnormalities – vitamin K, FFP, platelets
  • Urgent gastroenterology referral
  •  Medications:
    • Proton pump inhibitor – omeprazole / pantoprazole
    • Octreotide (in variceal bleeds – on gastroenterology advice)
  • Uncontrolled variceal bleeding may require ballon tamponade with Foley’s catheter or Sengstaken-Blakemore tube
  • All patients with significant upper GI bleeds should be admitted for observation and further management/investigation 
Mucosal Injury (post ingestion)
  • Button batteries lodged in the oesophagus require urgent endoscopic removal – refer urgently to gastroenterology
  • Button batteries in the stomach > 48 hours should be referred to gastroenterology for endoscopic removal
  • Caustic chemical ingestion should be discussed with gastroenterology especially if difficulty swallowing or excessive drooling  
Gastritis / Oesophagitis
  • Patients with an acute self-limiting bleed may benefit from acid suppression (H2 antagonist or proton pump inhibitor) for 2-4 weeks
  • Consider gastroenterology follow up if chronic or recurrent symptoms

References

Fleisher, Gary R.; Ludwig, Stephen; Textbook of Pediatric Emergency Medicine, 6th Edition. 2010

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