DEFINITION & PATHOPHYSIOLOGY
- Hematemesis: Expulsion of blood in vomitus.
- Source: Indicates upper gastrointestinal (UGI) bleeding proximal to ligament of Treitz (duodenojejunal flexure).
- Appearance: Bright red or "coffee-ground".
- Mechanism of Coffee-Ground: Degradation of heme by gastric acid signifies prolonged contact with gastric secretions.
- Associated Presentation: May present with melena (black tarry stools) or hematochezia (bright red blood per rectum) if transit is rapid.
ETIOLOGY BY AGE
| Age Group | Common Causes | Rare/Other Causes |
|---|---|---|
| Neonate/Infant | Swallowed maternal blood, Vitamin K deficiency (Hemorrhagic disease of newborn), Reflux esophagitis, Gastroduodenal erosions/ulcers (stress/sepsis). | Vascular malformations, Esophageal varices (>3-4 months), Duplication cyst, Cow milk allergy, Teratoma. |
| Preschool (2–5 yr) | Vomiting-induced (Mallory-Weiss tear, prolapse gastropathy), Acid-peptic disease, Esophageal varices (liver disease), Hemorrhagic gastritis, Caustic ingestion. | Bowel obstruction, Foreign body. |
| Older Child/Adolescent | Acid-peptic disease, Esophageal varices (liver disease), Mallory-Weiss tear, Reflux esophagitis, Hemorrhagic gastritis, Stress ulcer. | IgA vasculitis (Henoch-Schönlein purpura), Dieulafoy lesion, Hemobilia, Hemosuccus pancreaticus, Leiomyoma, Lymphoma. |
DIFFERENTIAL DIAGNOSIS OF SPECIFIC LESIONS
| Pathology | Clinical Features & Nuances |
|---|---|
| Esophageal/Gastric Varices | Painless, massive bleeding. Associated with portal hypertension, splenomegaly, ascites, caput medusae, cirrhosis, or extrahepatic portal venous obstruction (EHPVO). |
| Peptic Ulcer Disease (PUD) | Epigastric pain, nausea, weight loss. Associated with Helicobacter pylori, NSAID use, corticosteroids. Secondary ulcers linked to stress (Cushing/Curling ulcers). |
| Mallory-Weiss Syndrome | Mucosal tear at gastro-esophageal junction. History of nonbloody emesis/severe retching eventually converting to hematemesis. Self-limiting. |
| Swallowed Maternal Blood | Seen in neonates/breastfeeding infants. Bleeding from maternal nipple or swallowed during delivery. Diagnosed via Apt-Downey test (differentiates fetal from adult hemoglobin). |
| Foreign Body / Caustic Ingestion | History of ingestion. Dysphagia, drooling, stridor. Button batteries mandate emergent removal (<2 hours). |
| Dieulafoy Lesion | Abnormally enlarged submucosal arteriole. Presents as massive, abrupt GI hemorrhage in otherwise healthy child. |
EVALUATION & DIAGNOSIS
Initial Assessment & Bedside Tests
- Hemodynamic Assessment: Assess for shock, tachycardia, hypotension, orthostatic changes (increase in pulse >20 beats/min or decrease in systolic BP >10 mm Hg upon sitting).
- Physical Examination: Look for splenomegaly (most specific finding for varices in children). Check for jaundice, ascites, palmar erythema, spider nevi (chronic liver disease).
- Nasogastric (NG) Lavage: Normal saline lavage confirms UGI source and assesses for active, ongoing bleeding. Transpyloric (duodenal) bleeding may be missed.
- Apt-Downey Test: Mandatory in neonates/nursing infants to exclude swallowed maternal blood.
Laboratory Investigations
- Complete Blood Count (CBC): Baseline hemoglobin/hematocrit (may underestimate initial blood loss). Platelet count (thrombocytopenia in hypersplenism).
- Coagulation Profile: Prothrombin time (PT), Partial thromboplastin time (PTT), International normalized ratio (INR).
- Liver & Renal Chemistry: Transaminases, albumin, bilirubin. BUN/Creatinine ratio often elevated in UGI bleed (blood protein digestion).
- Blood Bank: Type and crossmatch immediately.
Endoscopic & Radiographic Imaging
- Esophagogastroduodenoscopy (EGD): Initial diagnostic procedure of choice. Provides direct visualization, identifies bleeding site, allows immediate therapeutic intervention. Contraindicated in hemodynamically unstable patients until resuscitated.
- Doppler Ultrasound: Essential for evaluating portal/hepatic vein patency, splenic size, and intra-abdominal abnormalities.
- CT/Conventional Angiography: Indicated for brisk, ongoing bleeding (>0.5 mL/min) when EGD fails or is contraindicated. Allows for selective microcoil embolization.
MANAGEMENT
1. Resuscitation & Stabilization (REO: Resuscitate, Evaluate, Operate)
- Maintain patent airway, oxygen supplementation.
- Establish two large-bore intravenous (IV) cannulas.
- Rapid volume replacement with isotonic crystalloids (Normal Saline).
- Blood Transfusion: Administer packed red blood cells (PRBCs). Target hemoglobin: 7 to 9 g/dL. Avoid over-transfusion to prevent rebound increase in portal pressure.
- Correct Coagulopathy: Administer Vitamin K, Fresh Frozen Plasma (FFP), or platelets as indicated.
2. Pharmacotherapy (Bridging to Endoscopy)
| Bleeding Type | Medications & Dosing | Rationale |
|---|---|---|
| Non-Variceal | Proton Pump Inhibitors (PPIs): IV Pantoprazole 2 mg/kg loading dose (max 80 mg), followed by 0.2 mg/kg/hr continuous infusion. | Raises intragastric pH, stabilizes clot formation, heals erosions/ulcers. |
| Variceal | Octreotide (Somatostatin analog): 1 mcg/kg IV bolus, followed by 1.0–5.0 mcg/kg/hr continuous infusion. Maintain for 24-48 hours post-bleeding cessation. | Splanchnic vasoconstriction; decreases portal venous flow and pressure. |
| Variceal | Antibiotic Prophylaxis: 3rd-generation cephalosporin (e.g., Ceftriaxone) for 7 days. | Reduces bacterial infection and mortality in cirrhotic patients with GI bleed. |
3. Endoscopic Therapy
- Timing: Perform within 12 hours of bleed onset, post-stabilization.
- Variceal Bleeding:
- Endoscopic Variceal Ligation (EVL): Procedure of choice (preferred over sclerotherapy due to lower rebleeding risk). O-ring strangulates varix causing fibrosis.
- Endoscopic Sclerotherapy (EST): Injection of 1% ethoxysclerol or sodium tetradecyl sulfate into variceal column. Used in smaller infants where EVL device cannot fit.
- Tissue Glue: N-butyl-2-cyanoacrylate injection. Standard for massive gastric varices.
- Non-Variceal Bleeding:
- Electrocoagulation (bipolar/heater probe), Argon plasma coagulation (APC).
- Epinephrine injection, endoscopic clips (hemoclips), or hemostatic powder.
4. Refractory Bleeding Interventions
- Balloon Tamponade: Sengstaken-Blakemore tube. Triple-lumen tube with esophageal and gastric balloons to mechanically compress bleeding varices. Used only as a temporary bridge.
- TIPS (Transjugular Intrahepatic Portosystemic Shunt): Interventional radiology establishes metallic stent between portal vein and hepatic vein. Bypasses liver resistance. Indicated for refractory variceal hemorrhage.
- Surgical Shunts: Meso-Rex bypass, portocaval shunt, or devascularization with esophageal staple transection for cases failing endoscopic/radiologic management.