Gastroinestinal bleeding upper GIT

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full CAHS clinical disclaimer.

Aim 

To guide Emergency Department (ED) staff with the assessment and management of upper gastrointestinal bleeding in children.

Definition

Gastrointestinal tract (GIT) bleeding in children is a relatively common presentation to emergency departments.

This guideline looks at upper GIT causes of bleeding. Please refer to Gastrointestinal Bleeding - Lower GIT for lower GIT causes.

Background² 

• Most causes of upper GIT bleeding in children are self-limiting conditions.
• In the rare event of a life-threatening upper GIT bleed urgent IV access (large bore) and resuscitation is paramount (refer to Serious illness – ED Guideline).
• Small, self-limiting GIT bleeds rarely need extensive investigation.

General

Upper GIT bleeding typically presents with:

• Haematemesis - frank blood or coffee ground
• Malaena

Assessment

Haemodynamically unstable, shocked or persistent large bleeding:

• Pallor, tachycardia, delayed perfusion, hypotension.
  • Large bore IV access x 2.
  • Fluid resuscitation 20mL/kg sodium chloride 0.9% (repeat as necessary).
  • +/- Blood transfusion.
  • Early senior clinician input.

Haemodynamically stable patients:

• Consider non GIT causes of blood.
  • Swallowed blood - maternal (breastfed infants), epistaxis, oral / dental injury, haemoptysis.
  • Food which can mimic blood - tomato, food colouring, beetroot.
  • Thorough history will help determine the source of bleeding.

History

Important points to ask in history:

• Neonates - was vitamin K given at birth?
• Non-steroidal anti-inflammatory drug (NSAID) use.
• Ingestion - button battery, caustic chemicals.
• Chronic liver disease.
• Cystic fibrosis.
• Family history of bleeding disorders, inflammatory bowel disease, peptic ulcer disease.

Differential Diagnoses^2,3

Diagnosis	History
Swallowed blood	Maternal blood, epistaxis, post oral/dental procedures
Mallory Weiss tear	Forceful vomiting
Oesophagitis	Reflux symptoms
Gastritis	Epigastric pain, NSAID use, Helicobactor pylori
Mucosal injury	Ingestion - button battery, caustic chemical
Oesophageal varices	Chronic liver disease, portal hypertension
Vascular malformation	Uncommon - may be cutaneous vascular malformations

Investigations

• Minor self-limiting upper GIT bleeds rarely require investigation and parental reassurance is all that is necessary
• Investigation of significant upper GIT bleeds should be guided by suspected underlying cause
• X-ray if suspected button battery ingestion.

Lab tests

• Full blood count
• Coagulation profile
• Group and hold or cross match
• Liver function tests
• APT-Downey test - differentiates adult haemoglobin (swallowed maternal blood) from foetal haemoglobin.

Endoscopy

• Significant upper GIT bleeds and mucosal injury should be referred to gastroenterology for endoscopy
• Urgent gastroenterology referral is required for patients with:
  • Haemodynamic instability
  • Active bleeding
  • Oesophageal varices
  • Button battery in oesophagus.

Management^2,4

Significant Bleeding

Large bore IV access x 2 Fluid resuscitation +/- blood transfusion as necessary Correct any clotting abnormalities - tranexamic acid, vitamin K, fresh frozen plasma, platelets Urgent gastroenterology referral Medications: Proton pump inhibitor e.g. omeprazole, pantoprazole, lansoprazole, esomeprazole. (Refer to Formulary One for available formulations and restrictions - internal WA Health link) Octreotide (in variceal bleeds - on gastroenterology advice). Refer to Octreotide Monograph – Medication Management Manual (internal WA Health link) Uncontrolled variceal bleeding may require ballon tamponade with Foley's catheter or Sengstaken-Blakemore tube All patients with significant upper GI bleeds should be admitted for observation and further management / investigation.

Mucosal injury (post-ingestion)

Button batteries lodged in the oesophagus require urgent endoscopic removal – refer urgently to gastroenterology. See Foreign Body – Oesophageal and Ingested – ED Guidelines Button batteries in the stomach > 48 hours should be referred to gastroenterology for endoscopic removal Caustic chemical ingestion should be discussed with gastroenterology especially if difficulty swallowing or excessive drooling.

Gastritis / Oesophagitis

Patients with an acute self-limiting bleed may benefit from acid suppression (H2 antagonist or proton pump inhibitor) for 2-4 weeks Consider gastroenterology follow up if chronic or recurrent symptoms.

Bibliography

1. AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd
2. Textbook of Paediatric Emergency Medicine 3rd Edition Cameron Elesevier 2018
3. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier, 2016
4. Fleisher, Gary R. Ludwig, Stephen. Textbook of Pediatric Emergency Medicine, 8th Edition. Wolters Kluwer. 2020

Endorsed by:	Nurse Co-Director, Surgical Services	Date:	April 2022
		Review date:	Sep 2025

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