Pediatric emergency medicine trisk 0692 0692
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anemia suggests chronic mucosal bleeding. Initial low white blood cell and platelet
counts may be seen in either hypersplenism from portal hypertension or sepsis with
associated mucosal ulceration due to stress. Abnormal hepatic studies, including an
elevation of serum bilirubin, transaminases, and prothrombin time, and a low serum
albumin, are suggestive of esophageal varices. A blood urea nitrogen to creatinine ratio
greater than 30 may indicate blood resorption and an upper GI source of bleeding.
Diagnostic Approach
If a significant upper GI bleed has occurred, and once hemodynamic stability is restored,
identification of the specific age-related disorder is the next step ( Table 33.1 and Fig.
33.2 ). If the bleeding is mild and self-limited or the gastric aspirate is negative, a minor
mucosal lesion is likely. Although mucosal lesions such as esophagitis, gastritis, or
peptic ulcer disease can present with severe bleeding, most often bleeding from mucosal
lesions is self-limiting and will respond to conservative medical management.
In patients who present with concern for swallowed foreign body, obstruction, or
perforation plain x-ray radiographs of the chest or abdomen may be diagnostic.
Abdominal ultrasonography can be helpful in patients where esophageal varices, liver
disease, or portal hypertension are a concern. Upper GI contrast radiography can be
helpful in determining obstructions and other irregularities of the GI tract, but should not
be performed in the setting of persistent or recurrent bleeding. In this setting, endoscopy
should be considered prior to the use of contrast radiography in which contrast material
obscures the bleeding source.
