Gastrointestinal bleeding
Key points
Definitions
Upper GI bleed: Proximal to the ligament of Treitz
Lower GI bleed: Distal to the ligament
Important causes by age
Neonate
Vitamin K deficiency
NEC
Swallowed maternal blood
Volvulus
Vascular malformation
Infants
Cows milk protein intolerance
Meckel diverticulum
Oesophagitis/Gastritis
Infectious colitis
Peptic ulcer
Intussusception
Volvulus
Button battery/foreign body/chemical ingestion
Vascular malformation
Avulsed rectal polyp
Children >5 years
All of above except cows milk protein intolerance, intussusception less common
Inflammatory bowel disease
Haemorrhoids
GI bleeding in renal failure patients
Acute GI bleeding in renal failure patients should be managed joint with the renal team and gastroenterologists
Citrate instead of heparin can be used for dialysis
Bowel resection should be a last resort in renal failure patients as likely future need for peritoneal dialysis and transplant
Angiodysplasia
On finding lesion, look elswhere in GI tract for other lesions
Can treat with octreotide
Endoscopy + laser/clips/sclerotherapy is mainstay
Do B12 and anaemia screen for all lesions
Can all predispose to volvulus
Peptic ulcer disease
Causes
Primary - More common in older children
H. Pylori - More common in older children
Urease - degrades urea to ammonia + CO2 - neutralises acid to survive
Bacterial enzymes disrupt mucus barrier, damage cells
Secondary - More common in younger children
Autoimmune gastritis
NSAIDS
Antral G cell hyperplasia
Zollinger-Ellison syndrome
In children, gastric ulcers tend to perforate at lesser curvature, duodenal ulcers perforate anteriorly
Investigation
Endoscopy
Biopsy + Clo test
Management
Proton pump inhibitor (PPI)
Antibiotics for H. Pylori eradication
If active bleed, endoscopic haemospray or clips can be applied
Standard scenario
Ensure resuscitated appropriately
Transfuse, PPI and tranexamic acid if required
History:
Determine if upper or lower GI bleed
Type of bleeding - altered/fresh blood
Foreign body ingestion
Previous bleeds
Co-morbidities and medications that may cause coagulopathies
Family history
Examination:
Anaemia
Abdominal masses
Investigation:
Dependent on possible cause
If unsure about location - can place NG tube and lavage
CT angiogram can sometimes locate bleed before theatre, and gives option of IR embolisation
Recognise that if bowel is embolised, it will likely have to be resected later
References
Aghighi M, Taherian M, Sharma A. Angiodysplasia. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549777/