Pediatric emergency medicine trisk 0691 0691
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hepatic parenchymal disorders such as neonatal hepatitis, congenital hepatic fibrosis,
cystic fibrosis, or biliary cirrhosis associated with biliary atresia. Two-thirds of patients
with portal hypertension develop bleeding before 5 years of age, and 85% do so by 10
years of age. In older children and adolescents, pill-induced (tetracyclines, NSAIDs, and
aspirin) esophagitis is another possibility. Helicobacter pylori infection has emerged as a
leading cause of secondary gastritis. In adolescent patients, alcohol binge drinking can
also contribute to gastritis and upper GI bleeding.
Evaluation and Decision: Upper Gastrointestinal Bleeding
History and Physical Examination
After ruling out hemorrhagic shock (see Chapter 10 Shock ), ask historical questions
about GI bleed imitators, bleeding onset and amount, upper versus lower GI bleeding
distinguishers, and associated symptoms. Pertinent historical elements to be sought
include a history of umbilical catheterization or sepsis in the neonatal period, previous
episodes of bleeding from the GI tract or other sites, and past hematologic disorders and
liver disease. A family history of peptic ulcer disease can be found in up to 30% of
patients with idiopathic ulcers. The presence of prior epigastric pain may suggest more
long-standing esophagogastritis or ulcer disease. Ingestions including tetracyclines,
aspirin, iron, NSAIDs, alcohol, and steroids should be sought as a possible cause.
Massive hemorrhage associated with right upper quadrant pain and jaundice in the
posttrauma patient indicates bleeding into the biliary tract (hemobilia).
The physical examination should include visualization of the anterior nose and
pharynx to eliminate epistaxis as a source of bleeding. Epigastric pain suggests peptic
ulcer disease. Signs of liver disease and/or portal hypertension with esophageal varices
may include icterus, abdominal distention, prominent abdominal venous pattern,
hepatosplenomegaly, cutaneous spider nevi, and ascites. As previously mentioned,
gastric lavage examination can help to diagnose an upper GI bleeding source. A rectal
examination for the detection of melena, hematochezia, and occult blood is crucial in all
cases of GI bleeding.
Laboratory Evaluation
If concerned about significant bleeding, a clinician should obtain a type and cross,
complete blood count, blood urea nitrogen, serum creatinine, transaminases, and
coagulation profile. Laboratory tests are not useful for identifying a precise cause of
upper GI bleeding, but can aid in narrowing the differential diagnosis.
Gastroccult tests can confirm the presence of blood in the vomitus. Gastroccult is a
specific and sensitive assay, and can detect as little as 300 mcg per dL of hemoglobin.
The Apt–Downey test can differentiate neonatal from maternal hemoglobin, but
obtaining sufficient vomited blood to perform this test may be difficult. Vitamin K–
deficient bleeding in neonates should be considered with prolongation of the
prothrombin time. A low mean corpuscular volume and hypochromic, microcytic
