UPPER GI BLEEDING Busara Charoenwat MD Pediatric Gastroenterology

UPPER GI BLEEDING Busara Charoenwat, MD. Pediatric Gastroenterology and Hepatology Department of Pediatric, KKU

Upper GI Bleeding

Epidemiology Pediatric Endoscopy Database System - Clinical Outcomes Research Intensive (PEDS-CORI) 5 % hematemesis (327 from 6337 patients) PICU 6 -25 % hematemesis Mortality rate 0. 4% • Bancroft J, et al. gastrointest endosoc 2003; 57: AB 121. • Chaibou M, et al. Pediatrics 1998; 102: 933 -8. • Cochran EB et al. Crit Care Med 1992; 20: 1519 -23.

Is it blood? Red color food Is the bleeding GI? Nasopharynx - Tomato, strawberry, spinach, Respiratory (hemoptysis) beetroot, iron GI

GI bleeding site UGIB/ LGIB UGIB/ MGIB/ LGIB UGIB MGIB Ligament of Triez LGIB ��. Classification of gastrointestinal bleedin �� 2553. �� 1 -3.

GI bleeding site Type Symptoms/ sign Site UGIB Hematemesis Above ampulla of EGD Coffee ground water Melena Maroon stool Anemia Obscure bleeding Ampulla of water - Enteroscopy terminal ileum Capsule enteroscopy Hematochezia Below terminal Colonoscopy Blood streak ileum MGIB LGIB Investigations

Modalities EGD Colonoscopy Capsule enteroscopy

Characteristics of the bleeding Hematemesis Coffee ground Melena Hematochezia

y of UGIB by age group Infants (0 -1 mo. ) Neonate-toddler (1 mo. - 1 yr) Older Esophagus Esophagitis Reflux esophagitis Mallory-Weiss tear Esophageal varices Pill esophagitis Caustic/ foreign body ingestion Stomach Stress gastritis Acid-peptic disease Gastric varices Gastric ulcer H. pylori gastritis Gastric polyp Duodenum NEC Duodenitis or duodenal ulcer Vascular malformation Crohn’s disese Others Swallowed maternal blood Hemorrhagic disease of the NB Vitamin K deficiency CMPA Vascular malformation • • • Gilger M, Whitfield K. Upper gastrointestinal bleeding. Walker's Pediatric Gastrointestinal Disease: 5 th ed; . 2008 p. . 1285 -90 Romano C, et al. World J Gastroenterol 2017; . 23: 1328 -37

UGIB: esophagus (A) Reflux esophagitis (B) Esophageal varices (C) Candida esophagitis

UGIB: stomach (D) Stress gastritis (E) Gastric varices (F) H. pylori infection (G) Fundic gland polyp

UGIB: duodenum (H) Duodenitis/ duodenal ulcer

UGIB: others (I) Dieulafoy lesion (J) (K) Gastric Crohn’s disease hemangioma

Diagnosis Varices Extrahepatic Intrahepatic Pre-sinusoid Sinusoid Post-sinusoid Non-varices Swallowed maternal blood CMPA Esophagitis Gastritis Biecker E. World J Gastroenterol 2013; . 19: 5035 -50

Portal hypertension Wyllie R. et al, Pediatric Gastrointestinal and Liver Disease. 2015; 9: 928 -43.

Variceal bleeding Extrahepatic/ pre-hepatic Intrahepatic Splenic vein thrombosis Pre-sinusoid Congenital hepatic fibrosis Idiopathic Sinusoid Cirrhosis Biliary atresia Post-sinusoid/post-hepatic Veno-occlusive disease Budd-chiari syndrome Portal vein thrombosis Arteriovenous fistula Extrinsic compression of the portal vein Signs of portal hypertension

Non-variceal bleeding Pathology site Neonate (0 -1 mo) Esophagitis Infant (1 mo – 1 yr) Reflux esophagitis Mallory-Weiss tear Stomach Stress gastritis Acid-peptic disease Gastric webs Duodenum NEC Duodenal webs/ ulcer Others Swallowed maternal Vascular blood malformation Hemorrhagic disease of NB Romano C, et al. World J Gastroenterol 2017; . 23: 1328 -37 CMPA Esophagus Childhood Reflux esophagitis Mallory-Weiss tear Foreign body/ caustic ingestion Stress gastritis Acid-peptic disease Infection Polyp Duodenal webs/ ulcer

Management Supportive treatment Specific treatment Variceal bleeding Non - variceal bleeding

Supportive treatment - Airway, Breathing, Circulation - Volumn status - NG/ SBBT - Blood components (keep Hb 7 -8 g/d. L) - Correct coagulopathy

Specific treatment Management Variceal bleeding Non - variceal bleeding Medications Vasoactive drugs ATB EVS/ EVL Acid suppression (PPI) Endoscopy Surgery Injection Thermocoagulation Mechanical device TIPS Portosystemic shunt • • • Romano C, et al. World J Gastroenterol 2017; . 23: 1328 -37 Laine L. N Engl J Med 2016; . 374: 2367 -76 Bozic MA , et al. Curr Gastroenterol Rep 2015; : 171 -8.

Acid secretion

Transjugular intrahepatic portosystemic shunt (TIPS)

Need for endoscopy? Thomson MA, et al. JPGN 2015; 60: 632– 36

Sheffield Scoring System Thomson MA, et al. JPGN 2015; 60: 632– 36.

ESPGHAN guideline Thomson MA, et al. JPGN 2017; 64: 133– 53.

EVS/ EVL EVS Pre - EVS Post - EVS EVL Pre - EVL Post - EVL

Mechanical device Hemoclips Thermocoagulation

Prophylaxis Modalities Endoscopy Nonselective β blockers Meso-Rex bypass shunt (EHPVT) Primary prophylaxis Secondary prophylaxis x X √ √

Meso-Rex bypass shunt Shneider BL, et al. Hepatology 2016; . 63: 1368 -80

Take home messages Required prompt attention Recognition Always remember: ABCD Required urgent co-operation Doctors management Nursing care Laboratory investigations Supportive/ specific treatment

Thank you!