Pediatric emergency medicine trisk 0687 0687
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into the stomach, resulting in a negative aspirate. In such a case, an upper GI endoscopy
will detect such a lesion. Patients with significant hematochezia or melena should
likewise have a nasogastric tube placed. As blood can exert a cathartic action, brisk
bleeding from an upper GI lesion may induce rapid transit through the gut, thus
preventing blood from becoming melanotic. In patients with hematochezia manifested as
bloody diarrhea or minimally blood-streaked stools, a lower GI source should be
investigated.
Gl bleeding
\
Hematochezia
i
Nasogastric tube
to aid treatment
I
\
Melena
Hematemesis
Massive
rectal bleeding
Nasogastric
tube
<+ )
(-)
Upper
Upper
Lower
Bloody diarrhea, or
minimal bright red
blood streaks
i
Lower
FIGURE 33.1 Establishing level of gastrointestinal (GI) bleeding.
UPPER GASTROINTESTINAL BLEEDING
Differential Diagnosis
As seen in Table 33.1 , there is considerable overlap between age groups and causes of
upper GI bleeding. Mucosal lesions, including esophagitis, gastritis, gastric and
duodenal ulcers, and Mallory–Weiss tears, are the most common sources of GI bleeding
in all age groups ( Table 33.2 ; see Chapter 91 Gastrointestinal Emergencies ). Of all
cases of upper GI bleeding in children, 95% are related to mucosal lesions and
esophageal varices. Coagulation disorders (e.g., disseminated intravascular coagulation,
von Willebrand disease, hemophilia, thrombocytopenia, liver failure, uremia, factor
deficiencies) should also be considered for all age groups as a cause of bleeding, but will
not be discussed in detail in this chapter (see Chapter 93 Hematologic Emergencies for
further details on coagulation disorders). Life-threatening causes of upper GI bleeding
are listed in Table 33.3 .
Neonatal Period (0 to 1 Month)
Hematemesis in a healthy newborn most likely results from swallowed maternal blood
either at delivery or during breast-feeding. In the breast-fed neonate with new onset of
hematemesis and maternal history of cracked nipples, who is well appearing and with
normal examination, one approach is to allow the mother to nurse (or use a breast pump)
