GASTROINTESTINAL

BLEEDING

ATAN BAAS SINUHAJI

Sub Division of Pediatrics Gastroentero-Hepatology

Department of Child Health, School of Medicine

University of Sumatera Utara/ Adam Malik Hospital

MEDAN

1

GI Bleeding

Acute

2

Stable

4 important points

GI bleeding

Blood ?

Gut

1

3

Gut

Out In

Upper or lower

Spesific site

2

3

4

Materials

Heme protein

4

Hydrogen peroxidase

Colorless guaiac Blue quinone

Tabel 1. Substances that interfere with Guaiac test

for fecal occult blood

False - Positive results

- Meat (rare or well-done)

- Horseradish

False -Negative results

-Vitamin C

- Storage of specimen > d

5

- Horseradish

- Turnips

- Ferrous sulfate (stool pH <6,0)- Tomatoes

- Fresh red cherries

- Storage of specimen > 4 d- Outdated reagent or card

GI BleedingGI Bleeding

Gut

6

Out In

Ingestion Non ingestion Upper Lower

Non ingestion

- Blood disorders : leukemia,ITP, etc

7

- Blood disorders : leukemia,ITP, etc

- Systemic : sepsis

- Rupture aortic aneurysma with enteric fistula

- Hemorrhagic Disease of the Newborn

Ingestion

Newborn

Swallowed maternal blood

Infants & young children

- Nipples

8

Swallowed maternal blood

APT Downey Test

- Nipples

- Epistaxis

- Oropharyngeal bleeding

- Blood tinged sputum

Newborn

Hb F Hb A Hb A2

9

50-90%

Alkali resistent

Manifestation of GI Bleeding

Blood per os Blood per anum

10

Hematemesis

Upper GIT

Occult Overt

Melena Hematochezia

Upper GIT

Hematochesia

With diarrhoea Without diarrhoea Without stools

11

Dysentry

syndrome

Blood strike

Anorectal area

•Anal fissure

•Polyps

Currant jelly

stools

Intussusception

GI Bleeding

Causes

12

Non lesion GIT Lesion GIT

Lesion GIT

Upper Lower

13

Mucosal

lesionVariceal

bleedingSurgical

Non

surgical

•Emergency

•ElectiveInflammation

Clinical presentationClinical presentation

•Hematemesis

•Melena

•Hematochezia

•Hystory & physical examination

•Laboratory evaluation

14

Stable

Nasogastric tube

Blood (+) Blood (-)

Upper GIT bleeding Lower GIT bleeding

•Contrast radiography

•Endoscopy

Gastric aspiration

The site of bleeding •The amount of bleeding

•The bleeding stop ?

15

Not totally exclude

upper GIT bleeding

•Competent pyloric

•No reflux

•Bleeding stopped

Clinical presentation

•Hystory and physical examination

•Laboratory evaluation

Stable

Nasogastric tube

Blood (+) Blood (-)

16

Upper GIT bleeding Lower GIT bleeding

Plain abdominal X-ray

(erect & supine)

Obstruction No obstruction

Barium enema

Surgery

•Stool examination / culture

•Meckel’s scan

•Double contrast barium enema

•Colonoscopy

Figure 2. A diagnostic approach

of lower bleeding GIT

Treatment

A General measures

BControl of upper

17

Treatment BControl of upper

GIT bleeding

CControl of lower

GIT bleeding

A General measures

1. To restore iv volume

& O2 carrying

capacity

2. To increased

hematocrit

•NaCl 0,9%

•Lactate Ringer

Blood/product

18

A General measureshematocrit

3. Underlying

coagulopathies

•Vit K 1 mg/year

(max 10 mg)

•Fresh Frozen Plasma

•Platelets

BControl of upper

Gastric lavage with ice saline

19

BControl of upper

GIT bleeding

Specific

Specific treatment of upper GIT bleeding

Mucosal lesion Variceal bleeding

20

Acid neutralizing /

supressor agent

•Vasoactive agent

•Balloon tamponade

•Sclerosing

•Surgery

Gastric lavage with ice saline

•Standart treatment

•Clearing of fresh blood and clots

21

•Clearing of fresh blood and clots

Adverse effect:

Hypothermia and electrolytes

abnormalities in infant

Gastric lavage with ice saline

� The recommended volume:

� 50 mL (infants)

� 100-200 mL (older children)

� Rapidly infused to stomach� Rapidly infused to stomach

� Allow to stay for 2-3 minutes and gently aspirated out

� The tube left in place to monitoring any

subsequent hemorrhage

22

Mucosal lesion

- Self limiting (spontaneously / ice saline)

- Acid neutralizing / supressor agent

23

Do not stop active bleeding

Antacid 1 mL/kg/dose (max 30 mL/dose)•Every 1-2 hours � gastric pH ≥5

•Thereafter: 1-3 hours after meal & at bed time

6 weeks

Variceal bleeding

Stop spontaneously

Vasoactive agent

(vasopressin & octreotide)

24

(vasopressin & octreotide)

Splanchnic arterial

blood flow ↓↓

Portal pressure ↓↓

Variceal bleeding

Radical/surgical consultation

ICU

Resuscitation

25

Endoscopy to visualize varices

Vasoactive agent

Sengstaken – Blackmore tube

Sclerosing therapy Emergency therapy

Figure 3. An approach to the management of variceal bleeding

VASOPRESSIN

� Bolus dose: 0,3 U/kg (max 20 U/kg) dilluted in

2 mL/kg 5% Dextrose � 20 minutes

� Continous infusion: 0,2-0,4 U/1,73m2/min,if necessarynecessary

� The bleeding cases: the infant is maintained

at the initial dose for 12 hours and then

gradually tapered � 24-36 hours

� Side effect: hypertension, myocardial

ischemic, arrhythmias, water retention and

venous thrombosis26

OCTREOTIDE

� Bolus dose: 1 μg/kg

� Continued infusion: 1 μg/kg/h with titration

of both bolus and constant infusion up to 5μg/kg/h μg/kg/h

� The bleeding cases: doses should be tapered

by 50% for 12 hours, can be discontinued

when dose is 25% initial dose

27

Balloon tamponade

Sengstaken-Blackmore tube

Indication:

•Massive life threatening bleeding

•Continued bleeding despite 4-6 hours

28

•Continued bleeding despite 4-6 hoursof i.v. vasopressin

Complication:

•Ulceration

•Airway obstruction

•Aspiration

•Esophageal rupture

C Control of lower GIT bleeding

29

•Severe lower GIT bleeding is uncommon

•Definitive treatment: depend on the cause

B � Ongoing bleeding

L � Low systolic blood pressure

E � Elevated prothrombine time

30

E � Elevated prothrombine time

E � Erratic in mental status

D � Comorbid disease (other thanbleeding) requiring admission

to ICU

Figure 4, Predictors of outcome

CONCLUSION

GI Bleeding

Not unusual

Life threatening problem

31

Life threatening problem

Stable

Bleeding source

Thank Thank Thank Thank

YouYouYouYou

32