Upper Gastrointestinal Bleeding

Descriptive text is not available for this imageBASICS

DESCRIPTION

  • Upper gastrointestinal bleeding (UGIB) is classified based on its origin of bleeding being proximal to the ligament of Treitz.
  • The classic clinical symptom is hematemesis, that is, emesis of bright red blood or coffee ground.
  • Other symptoms include melena (black tarry stool) and, in the case of severe UGIB, hematochezia.

EPIDEMIOLOGY

  • The incidence of UGIB in children is not well established in the general population.
  • Large prospective studies have assessed the prevalence of UGIB in pediatric critical care settings to range from 6.4% to 25% of admissions.
  • 80% of UGIB stops spontaneously.

ETIOLOGY

  • Neonatal period (birth to 1 month)
    • Swallowed maternal blood
    • Necrotizing enterocolitis
    • Gastrointestinal (GI) malformation (i.e., duodenal web, antral web, GI duplication)
    • Hemorrhagic disease of the newborn
    • Cow’s milk protein allergy
  • Infancy (1 month to 2 years)
    • Cow’s milk protein allergy
    • Duplication cysts
  • Preschool age (2 to 5 years)
    • Esophageal varices
    • Foreign body/bezoar
    • Caustic ingestion
    • Mallory-Weiss tear
  • School age (>5 years)
    • Esophageal varices
    • Mallory-Weiss tear
    • Inflammatory bowel disease (IBD)
  • All ages:
    • Peptic ulcer disease (except infants), especially Helicobacter pylori
    • Esophagitis/gastritis/duodenitis (infectious, allergic, or inflammatory)
    • Caustic/foreign body ingestion
    • Foreign body irritation (i.e., nasogastric [NG] tube–associated trauma)
    • Medications
    • Coagulopathy (associated with and without liver failure), coagulation disorders
    • Vascular malformations
    • Polyps
    • Anastomotic ulcers (patients with prior GI surgery)

RISK FACTORS

  • Medications (i.e., nonsteroidal anti-inflammatory drugs [NSAIDs], aspirin, anticoagulants, mammalian target of rapamycin (mTOR) inhibitors)
  • Major stressors (i.e., shock, organ failure, trauma, operative procedures >3 hours long, mechanical ventilation)

Genetics

  • Genetic polymorphisms involved in platelet activation and aggregation, angiogenesis, inflammatory process, and drug metabolism can be associated with increased risk of nonvariceal UGIB.
  • Polyposis syndromes (i.e., juvenile polyposis syndrome [JPS], Bannayan-Riley-Ruvalcaba syndrome [BRRS], Cowden syndrome, Peutz-Jeghers syndrome [PJS], familial adenomatous polyposis [FAP], Gardner syndrome)
  • Vascular malformations (i.e., hereditary hemorrhagic telangiectasia or Osler-Weber-Rendu syndrome, Klippel-Trenaunay syndrome, blue rubber bleb nevus syndrome)

GENERAL PREVENTION

  • Avoid or minimize the use of drugs that can lead to peptic ulcers (i.e., NSAIDs, aspirin).
  • Consider prophylactic acid suppression for children in critical medical condition or on high dose corticosteroids.

COMMONLY ASSOCIATED CONDITIONS

  • Peptic ulcer disease
  • Conditions that predispose to the development of cirrhosis and portal hypertension
  • Disorders associated with GI and vascular malformations
  • Polyposis syndromes
  • Coagulation disorders
  • Sickle cell disease (i.e., duodenal ulcer from ischemia-induced mucosal lesions)

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