Gastrointestinal Bleeding
Leah Harrington
Introduction
Upper gastrointestinal bleeding
Hematemesis: bleeding proximal to ligament of Treitz
Melena: black, tarry stools, bleeding proximal to ileocecal valve
Lower gastrointestinal bleeding
Hematochezia: bright red blood per rectum
Assessment
Is the child hemodynamically stable?
Is this blood?
For infants: maternal vs infant blood?
Is this an upper or lower gastrointestinal hemorrhage?
What are the specific diagnosis and site of the hemorrhage?
Table 27.1 Substances Mistaken for Blood in Emesis and Stool | |||||||||||||||||||||||
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Apt-Downey Test: Maternal vs Infant Blood
Mix stool or emesis with water (1:5), centrifuge mixture
Add 1 mL 0.25% sodium hydroxide to 5 mL supernatant—wait 5 minutes
Adult hemoglobin = brown-yellow
Fetal hemoglobin = pink
Stool Guaiac (Occult Blood) Test
Identifies gross/occult blood in stool
Acute Stabilization
Assess for signs of intravascular volume depletion
•
< 15%
No hemodynamic change
•
> 15%
Tachycardia
•
> 30%
Hypotension
Elevate head of the bed
Place large-bore IV lines × 2
Volume replacement with crystalloid 10-40 mL/kg depending on status
CBC, INR, PTT, consider liver function tests, cross and type for blood
Vitamin K 5-10 mg IV/IM if elevated INR or known liver disease (keep anaphylaxis kit at bedside for IV dose)
Table 27.2 Causes of Upper Gastrointestinal Bleeding | |||||||||||||||||||||||||||||||||
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Additional Stabilization for Upper GI Bleed
Large-bore NG tube: decompression of stomach, confirmation of UGI bleeding, indication of rate of blood loss
Pantoprazole (Pantoloc®)
•
5-15 kg:
2 mg/kg IV bolus followed by continuous infusion 0.2 mg/kg/hr
•
15-40 kg:
1.8 mg/kg IV, then infusion 0.18 mg/kg/hr
•
> 40 kg:
80 mg IV, then infusion 8 mg/hr
Severe bleeding (especially from variceal source):
Octreotide (Sandostatin®) 1 mcg/kg bolus; continuous infusion 1 mcg/kg/hr
Consider endoscopy with gastroenterology consultation
Transfusion as Required
PRBCs, fresh frozen plasma, platelets
FFP to correct coagulation abnormalities, or with every 2-3 units of PRBCs for ongoing loss of coagulation factors
Platelets reserved for patients with platelet count < 50
UGI Bleeding—Esophageal Varices
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