Pediatric emergency medicine trisk 2044 2044
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thrombocytopenia, or hypoalbuminemia. In addition to primary liver disease,
patients with congestive heart failure are known to be at high risk for EV.
These factors should be taken into account when evaluating a patient with a
history of an upper GI bleed or when counseling families for their risk of
upper GI bleed.
Clinical Considerations
Clinical Recognition. Patients with EV may have occult bleeding, but more
commonly, the bleeding is brisk. Patients will have hematemesis,
hematochezia, and/or melena. The possibility of bleeding EV should be
considered in any patient with a history of jaundice (beyond the newborn
period), hepatitis, ascites, chronic right-sided heart failure, portal vein
thrombosis, pulmonary hypertension, omphalitis, umbilical vein
catheterization, or one of the hepatic parenchymal diseases noted in Table
91.1 .
Triage Considerations. While it is common that bleeding will have stopped
prior to arrival in the ED, patients with EV have the potential for significant
blood loss. Close attention should be given to tachycardia as an early indicator
of hemodynamic compromise and patients should be triaged accordingly.
Patients with significant upper GI bleeding may also be at risk for airway
compromise.
Clinical Assessment. One should have a high suspicion of EV in any patient
presenting with an upper GI bleed and any of the risk factors listed above. One
can also evaluate for the stigmata of portal hypertension, such as jaundice,
ascites, rectal hemorrhoids, and hepatosplenomegaly ( Table 91.2 ). Other
signs or symptoms of right-sided heart failure would also place a patient at
higher risk. Given the risk for sudden and life-threatening bleeding, assessing
this risk is essential.
In patients with severe upper GI bleeding from EV, two large-bore IVs
should be started immediately ( Fig. 91.1 ). A nasogastric (NG) tube should be
placed to evaluate for ongoing bleeding and to remove blood from the
stomach, which may act as an irritant and potentially worsen hepatic
encephalopathy. Variceal bleeding is not a contraindication for passing an NG
tube. Immediate laboratory studies should include type and crossmatch,
